This is a Federal Deposit Insurance Corporation (FDIC) computer system. This computer system may be
monitored by the FDIC for lawful purposes. All information (including personal and confidential)
placed on or sent over this system may be examined, recorded or copied, used or disclosed by the
FDIC for authorized purposes. Any information collected during monitoring may be used for purposes
of any administrative, civil or criminal action or proceeding.
The Federal Deposit Insurance Act (12 U.S.C. §§1819 and 1821) and Executive Order 9397 authorize the
collection of this information. The FDIC will use the information to assist in the determination and/or
payment of claims against the receivership estate of the failed financial institution. Submitting this
information to the FDIC is voluntary. Failure, however, to submit all of the information requested and
to complete the form entirely could delay or preclude the administration of claims against the receivership
estate of the failed financial institution. 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 Insured Financial Institution Liquidation
Records (FDIC-30-64-0013) System of Records. A complete copy of this System of Records is available at
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.