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

The collection of this information is authorized by Section 9 of the Federal Deposit Insurance Act (12 U.S.C. §1819) and Section 202(f) of Title II of the Federal Trade Improvement Act (15 U.S.C. §57a(f)).  The FDIC will use this information to respond to your questions and requests for assistance involving activities or practices of FDIC-insured depository institutions.   Submitting this information to the FDIC is voluntary.   Failure to submit all of the information requested and to complete the form entirely could delay or prevent the response to your request.  The information provided by individuals is protected by the Privacy Act, 5 USC §552a.  The information may be furnished to third parties as authorized by law or used according to any of the other routine uses described in the FDIC Consumer Complaint and Inquiry Records System of Records (FDIC-30-64-0005).  A complete copy of this System of Records is available at http://www.fdic.gov/regulations/laws/rules/2000-4000.html#fdic200030--64--0005.   If you have questions or concerns about the collection or use of the information, you may contact the FDIC’s Chief Privacy Officer at Privacy@fdic.gov.