FDIC: Forms

Forms

FDIC, interagency and Federal Financial Institutions Examination Council forms for applications, reports, doing business with the FDIC, and other administrative matters:

FDIC & Interagency Forms
•	Bank Supervision - Applications - Reports & Notices
•	Deposit Claims & Asset Sales
•	Doing Business with the FDIC - Contracting & Leasing - Financial Management - Leasing - Legal Services
•	Personnel Administration

FFIEC Forms
•	Federal Financial Institutions Examination Council Forms at the FFIEC website.

The forms are Adobe® PDF file or Microsoft® Word files. Information on downloading and using these files is at: PDF Help & Word Help.

Bank Supervision - Applications

Form Title	Form Number	File size
Application for Consent to Exercise Trust Powers Adobe® PDF file Microsoft® Word file	FDIC 6200/09	183 kb 91 kb
Form 3: Initial Statement of Beneficial Ownership of Securities (Formerly Form F-7) Adobe® PDF file Microsoft® Word file • Form 3 Instructions	FDIC 6800/03	379 kb 140 kb 57 kb
Form 4: Statement of Changes in Beneficial Ownership of Securities (Formerly Form F-8) Adobe® PDF file Microsoft® Word file • Form 4 Instructions	FDIC 6800/04	274 kb 240 kb 62 kb
Form 5: Annual Statement of Beneficial Ownership of Securities (Formerly Form F-8A) Adobe® PDF file Microsoft® Word file • Form 5 Instructions	FDIC 6800/05	260 kb 189 kb 66 kb
Interagency Bank Merger Act Application Adobe® PDF file Microsoft® Word file	FDIC 3064-0015	116 kb 111 kb
Interagency Charter and Federal Deposit Insurance Application Adobe® PDF file Microsoft® Word file	FDIC 3064-0001	226 kb 586 kb
Loan/Application Register (Formerly FDIC 6440/12) Adobe® PDF file Microsoft® Word file		55 kb 47 kb

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Bank Supervision - Reports & Notices

Form Title	Form Number	File size
Interagency Biographical and Financial Report Adobe® PDF file Microsoft® Word file	FDIC 3064-0006	160 kb 444 kb
Interagency Notice of Change in Control Adobe® PDF file Microsoft® Word file	FDIC 3064-0019	133 kb 213 kb
Interagency Notice of Change in Director of Senior Executive Officer Adobe® PDF file	FDIC 3064-0097	144 kb
Notice and Authorization Pertaining to Consumer Reports Pursuant to the Fair Credit Reporting Act of 1970, 15 U.S.C. § 1681, et seq. Adobe® PDF file Microsoft® Word file	FDIC 1600/10	44 kb 34 kb
Notice by Financial Institutions of Government Securities Broker or Government Securities Dealer Activities Adobe® PDF file	G-FIN	28 kb
Notice by Financial Institutions of Termination of Activities as a Government Securities Broker or Government Securities Dealer Adobe® PDF file	G-FINW	20 kb
Notification of Performance of Bank Services Adobe® PDF file Microsoft® Word file	FDIC 6120/06	1351 kb 54 kb
Registered Transfer Agents Form for Registrations and Updating Amendments Adobe® PDF file	Form TA-1	320 kb
Uniform Application for Municipal Securities Principal or Municipal Securities Representative Associated With a Bank Municipal Securities Dealer Adobe® PDF file	MSD 4	14 kb
Uniform Termination Notice for Municipal Securities Principal or Municipal Securities Representative Associated with a Bank Municipal Securities Dealer Adobe® PDF file	MSD 5	156 kb
Uniform Termination Notice for Person Associated with a Financial Institution Government Securities Broker or Dealer Adobe® PDF file	GFIN-5	112 kb
Summary of Deposits	External Link
Suspicious Activity Report Adobe® PDF file Microsoft® Word file	FDIC 6710/06	153 kb 200 kb

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Deposit Claims & Asset Sales
Instructions for completing the Deposit Claims forms and Mailing/Fax information

Form Title	Form Number	File size
Declaration for Custodian Deposit Adobe® PDF file Microsoft® Word file	FDIC 7200/13	41 kb 65 kb
Declaration for Defined Benefit Plan Adobe® PDF file Microsoft® Word file	FDIC 7200/12	73 kb 48 kb
Declaration for Defined Contribution Plan Adobe® PDF file Microsoft® Word file	FDIC 7200/10	85 kb 58 kb
Declaration for Health and Welfare Plan Adobe® PDF file Microsoft® Word file	FDIC 7200/14	73 kb 42 kb
Declaration for IRA/KEOGH Deposit Adobe® PDF file Microsoft® Word file	FDIC 7200/11	71 kb 44 kb
Declaration of Independent Activity Adobe® PDF file Microsoft® Word file	FDIC 7200/06	117 kb 57 kb
Declaration of Independent Activity for Unincorporated Association Adobe® PDF file Microsoft® Word file	FDIC 7200/07	70 kb 59 kb
Declaration for Joint Ownership Deposit Adobe® PDF file Microsoft® Word file	FDIC 7200/08	76 kb 55 kb
Declaration for Plan and Trust Adobe® PDF file Microsoft® Word file	FDIC 7200/15	72 kb 47 kb
Declaration for Power of Attorney Adobe® PDF file Microsoft® Word file	FDIC 7200/16	45 kb 35 kb
Declaration for Public Unit Deposit Adobe® PDF file Microsoft® Word file	FDIC 7200/04	78 kb 54 kb
Declaration for Testamentary Deposit (Multiple Grantors) Adobe® PDF file Microsoft® Word file	FDIC 7200/09	75 kb 70 kb
Declaration for Testamentary Deposit (Single Grantor) Adobe® PDF file Microsoft® Word file	FDIC 7200/03	60 kb 47 kb
Declaration for Trust Adobe® PDF file Microsoft® Word file	FDIC 7200/05	66 kb 73 kb
Power of Attorney Adobe® PDF file Microsoft® Word file	FDIC 7200/17	39 kb 41 kb
Purchaser Eligibility Certification Adobe® PDF file Microsoft® Word file	FDIC 7300/06	117 kb 57 kb

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Doing Business with the FDIC - Contracting and Leasing

Form Title	Form Number	File size
Background Investigation Questionnaire for Contractor Personnel & Subcontractors Adobe® PDF file Microsoft® Word file	FDIC 1600/04	417 kb 94 kb
Background Investigation Questionnaire For Contractors Adobe® PDF file Microsoft® Word file	FDIC 1600/07	63 kb 60 kb
Confidentiality Agreement for Contractors Microsoft® Word file	FDIC 3700/46	37 kb
Confidentiality Agreement for Contractor Personnel Microsoft® Word file	FDIC 3700/46A	34 kb
Cover and Signature Pages Microsoft® Word file		21 kb
FDIC Integrity and Fitness Representations and Certifications Adobe® PDF file Microsoft® Word file	FDIC 3700/12	163 kb 183 kb
FDIC Leasing Representations and Certifications Adobe® PDF file Microsoft® Word file	FDIC 3700/44	209 kb 205 kb
FDIC Contractor Representations and Certifications Adobe® PDF file Microsoft® Word file	FDIC 3700/04A	245 kb 137 kb
Notice and Authorization Pertaining to Consumer Reports Adobe® PDF file Microsoft® Word file	FDIC 1600/10	35 kb 100 kb
Part 366 - Minimum Standards of Integrity and Fitness for an FDIC Contract	External Link
Payee Information for Automatic Deposit of Payment Adobe® PDF file Microsoft® Word file	FDIC 4531/09	105 kb 57 kb
Request for Taxpayer Identification Number & Certification Adobe® PDF file Microsoft® Word file	FDIC 4531/10	52 kb 80 kb
Voluntary Product Accessibility Template (VPAT)	External Link

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Doing Business with the FDIC - Financial Management

Form Title	Form Number	File size
Payee Information for Automatic Deposit of Payment Adobe® PDF file Microsoft® Word file	FDIC 4531/09	105 kb 57 kb
Substitute Form W9, Request for Taxpayer Identification Number and Certification Adobe® PDF file Microsoft® Word file	FDIC 4531/10	52 kb 80 kb

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Doing Business with the FDIC - Legal Services

Form Title	Form Number	File size
Agreement for Services (Expert/Legal Support Services (LSS) Provider) Amendment Adobe® PDF file Microsoft® Word file	FDIC 5210/03	84 kb 80 kb
Agreement for Services (Expert/Legal Support Services (LSS) Provider) Amendment Adobe® PDF file Microsoft® Word file	FDIC 5210/03A	93 kb 86 kb
Agreement for Services (Expert/Legal Support Services (LSS) Provider) Rate Schedule Adobe® PDF file Microsoft® Word file	FDIC 5210/04	88 kb 80 kb
Agreement for Services (Expert/Legal Support Services (LSS) Provider) Rate Schedule (Continuation Sheet) Adobe® PDF file Microsoft® Word file	FDIC 5210/04A	80 kb 88 kb
Expert Budget Adobe® PDF file Microsoft® Word file	FDIC 5210/08	91 kb 54 kb
Expert Invoice for Fees and Expenses (EIF&E) Adobe® PDF file Microsoft® Word file	FDIC 5210/01	84 kb 65 kb
Law Firm Travel Voucher Adobe® PDF file Microsoft® Word file	FDIC 5210/12	235 kb 115 kb
Law Firm Travel Voucher (Continuation Sheet) Adobe® PDF file Microsoft® Word file	FDIC 5210/12A	174 kb 147 kb
Legal Invoice for Fees and Expenses Adobe® PDF file Microsoft® Word file	FDIC 5210/11	139 kb 61 kb
Legal Services Agreement Adobe® PDF file Microsoft® Word file	FDIC 5210/13	126 kb 54 kb
Legal Services Agreement (LSA) Amendment Adobe® PDF file Microsoft® Word file	FDIC 5210/06	88 kb 86 kb
Legal Services Agreement (LSA) Amendment (Continuation Sheet) Adobe® PDF file Microsoft® Word file	FDIC 5210/06A	115 kb 140 kb
Legal Support Services (LSS) Provider Budget Form Adobe® PDF file Microsoft® Word file	FDIC 5210/15	219 kb 74 kb
Legal Support Services (LSS) Provider Invoice for Fees and Expenses (IF&E) Adobe® PDF file Microsoft® Word file	FDIC 5210/02	78 kb 82 kb
Litigation Budget Adobe® PDF file Microsoft® Word file	FDIC 5000/35	124 kb 64 kb
Non-Litigation Budget Adobe® PDF file Microsoft® Word file - Amended Litigation Budget Form Adobe® PDF file Microsoft® Word file	FDIC 5000/26 FDIC 5000/31	157 kb 119 kb 108 kb 67 kb
Amended Non-Litigation Budget Adobe® PDF file Microsoft® Word file	FDIC 5000/33	110 kb 71 kb
Oral Representations and Certifications for Expert Legal Support Services Telephone Authorization for Expenditures Under $5,000 Adobe® PDF file Microsoft® Word file	FDIC 5210/14	205 kb 51 kb
Outside Counsel Legal Services Agreement (LSA) Rate Schedule Adobe® PDF file Microsoft® Word file	FDIC 5210/10	97 kb 86 kb
Outside Counsel Legal Services Agreement (LSA) Rate Schedule (Continuation Sheet) Adobe® PDF file Microsoft® Word file	FDIC 5210/10A	103 kb 96 kb
Representations and Certifications for Experts and Legal Support Services Provider Adobe® PDF file Microsoft® Word file	FDIC 5210/09	55 kb 51 kb
Representations & Certifications for Legal Contractors Adobe® PDF file Microsoft® Word file	FDIC 5200/01	94 kb 66 kb

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Personnel Administration

Form Title	Form Number	File size
Applicant Background Questionnaire Adobe® PDF file Microsoft® Word file	FDIC 2100/14	89 kb 50 kb
Applicant Certification Statement Adobe® PDF file Microsoft® Word file	FDIC 2120/16	385 kb 73 kb
Application for Student Educational Employment Program Adobe® PDF file Microsoft® Word file	FDIC 2100/08B	128 kb 120 kb
Medical History Questionnaire Adobe® PDF file Microsoft® Word file	FDIC 2820/06	52 kb 72kb

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Last Updated 08/14/2008

Records@FDIC.GOV


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