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 - Legal Services (E-Billing)
•	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	900 kb
Uniform Termination Notice for Municipal Securities Principal or Municipal Securities Representative Associated with a Bank Municipal Securities Dealer Adobe® PDF file	MSD-5	450 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

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 The Purchaser Eligibility Certification for a specific sale will be available on the website of the loan sale adviser responsible for that sale. Purchasers will complete that form and provide it to the loan sale adviser. In order to self screen, Potential Purchasers can review this sample copy of the Purchaser Eligibility Certification.	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 Microsoft® Word file		67 kb
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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Doing Business with the FDIC – Legal Services (E-Billing)

Form Title	Form Number	File size
Legal Services Agreement Adobe® PDF file Microsoft® Word file	FDIC 5210/13E	37 kb 66 kb
Legal Services Agreement E-Billing Amendment Adobe® PDF file Microsoft® Word file	FDIC 5210/06E	37 kb 123 kb
Legal Services Agreement E-Billing Amendment (Continuation Sheet) Adobe® PDF file Microsoft® Word file	FDIC 5210/06A-E	36 kb 162 kb
Outside Counsel Legal Services Agreement E-Billing Rate Schedule Adobe® PDF file Microsoft® Word file	FDIC 5210/10E	133 kb 63 kb
Outside Counsel Legal Services Agreement E-Billing Rate Schedule (Continuation Sheet) Adobe® PDF file Microsoft® Word file	FDIC 5210/10A-E	154 kb 35 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: 08/05/2009

Records@FDIC.GOV


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