FDIC:Customer Assistance Form


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OMB Number: 0164-013
Expiration Date: 4/30/2009

Customer Assistance Form

Privacy Act Statement

Paperwork Reduction Act Notice

Indicate whether you are a: Consumer OR Banker

Requester Information:

E-mail Address

Phone Number

Last Name

First Name

Street Address, line 1

Street Address, line 2

City

State

Zip

Zip Ext

If this request is submitted on behalf of you and another individual, complete this section:

E-mail Address

Phone Number

Last Name

First Name

Same address as above? No Yes

Street Address, line 1

Street Address, line 2

City

State

Zip

Zip Ext

If your request involves a specific financial institution, complete the following information:

Institution Name

Street Address, Line 1

Street Address, Line 2

City

State

Zip

Zip Ext

Select one of the following that best describes your request:

Complaint Deposit Insurance Inquiry Other Inquiry

Please describe below the nature of your complaint or inquiry.

Use single quote marks rather than double quotes, if any.

FDIC 6422/04 (10-05)
Last Updated 07/27/2007	consumeralerts@fdic.gov