Each depositor insured to at least $250,000 per insured bank

OMB Number: 3064-0134 
Expiration Date: 8/31/2015
Business Assistance Form
Privacy Act Statement Paperwork Reduction Act Notice

Please complete this form if you represent a business and have an inquiry or concern about a financial institution. Once the form has been submitted, you will receive a Confirmation Page indicating that your request has been received.

Please note:
  • We cannot act as a court of law or as a lawyer on your behalf.
  • We cannot give you legal or financial advice.
  • We cannot become actively involved in matters that are in litigation or have been litigated.
* Required Fields
 
Requester Information:
Name of Business Contact
*Business Name  
*Salutation   
Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
Contact Phone Number   
Alternate Phone Number   
*Country  
  What is the best way to contact you?    Phone    Mail    E-mail
  What is the best time to contact you?    Morning    Afternoon    Evening
 
Is this request submitted by a third party on behalf of the business? Yes  No
Name and Contact Information for Business Representative
Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
Contact Phone Number   
Alternate Phone Number   
*Country  
 
 
Additional Contact Information:
 
Do you want us to communicate with another individual on your behalf, such as an advisor, attorney, or other person representing you? Yes  No
If you list someone below, you authorize us to communicate with the individual and provide information to that individual.
 
*Representative Last Name    *First Name   
Relationship    E-mail Address   
Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
Contact Phone Number   
Alternate Phone Number   
*Country  
 
Does your request involve a specific financial institution? Yes  No
 
*Country  
   Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
Type of account(s)    Credit Card Deposit Account Real Estate Loan Other Business Loan Other
 
MM/DD/YYYY   *How?   Phone  Mail  In Person  Other 
Contact Name    Title   
 
 
Inquiry Information:
 
Describe your inquiry or concern, including any names, phone numbers, and a full description of the issue with the amount(s) and date(s) of any transaction(s). Do not include personal or confidential information such as your social security, credit card, or bank account numbers. If you need to provide COPIES of any supporting documentation such as contracts, monthly statements, receipts or any correspondence with the bank (do not send original documents), you may mail or fax this information to:
FDIC Consumer Response Center
1100 Walnut Street, Box #11
Kansas City, MO 64106
1-877-ASK-FDIC (1-877-275-3342)
(Monday - Friday 8:00 am to 8:00 pm EST)
703-812-1020 (Fax number)
 
*Please describe below the nature of your inquiry or concern.
Use single quote marks rather than double quotes, if any.
 
Please be advised that the FDIC may contact your financial institution or company to obtain additional information needed to respond to your inquiry or concern.
 
*Desired Resolution
What action by the financial institution or company would resolve this matter to your satisfaction?
 
 
*Checking this box authorizes the FDIC to respond and investigate (if applicable) your concerns.
 
 

FDIC 6422/11 (9-12)
Last Updated 09/21/2012 consumeralerts@fdic.gov