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OMB Control No: 3064-0057	ICR Reference No: 202608-3064-002
Status: Received in OIRA	Previous ICR Reference No: 202311-3064-006
Agency/Subagency: FDIC	Agency Tracking No:
Title: Certified Statement for Deposit Insurance Assessment
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 09/16/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	10/31/2026
Responses	17,380	19,020
Time Burden (Hours)	5,793	6,340
Cost Burden (Dollars)	0	0

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Robert Meiers 571 645-3062 romeiers@fdic.gov

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