OMB control number

Certified Statement for Deposit Insurance Assessment

OMB 3064-0057 · FDIC.

OMB 3064-0057

The FDIC collects the quarterly deposit insurance payments by means of direct debits through the Automated Clearing House network. This information collection consists of statements supported by worksheets and reviewed by officials of the insured institutions to confirm that the assessment data is accurate.

The latest form for Certified Statement for Deposit Insurance Assessment expires 2026-09-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 6420-07 Certified Statement for Deposit Insurance Assessment Form and Instruction
Justification Memo Non Substantive Revisions 3064-0057 Novemebr 2023.docx Justification for No Material/Nonsubstantive Change
SPST 0057 Certified Statement of Semiannual Deposit Insurance Assessment 2023 Extension FINAL docx.docx Supporting Statement A
FR2 0057 Certified Statement of Semiannual Deposit Insurance Assessment 88 FR 44803 July 13 20223.pdf Supplementary Document
FR1 0057 Certified Statement of Semiannual Deposit Insurance Assessment 88 FR 27891 May 3 20223.pdf Supplementary Document
Certified Statement for Deposit Insurance Assessment Form and Instruction

All Historical Document Collections

202311-3064-006 Approved without change	No material or nonsubstantive change to a currently approved collection	2023-11-30
202304-3064-003 Approved without change	Extension without change of a currently approved collection	2023-07-13
202003-3064-002 Approved without change	Extension without change of a currently approved collection	2020-05-27
201609-3064-006 Approved without change	Revision of a currently approved collection	2016-12-06
201305-3064-002 Approved without change	Revision of a currently approved collection	2013-09-09
201008-3064-004 Approved without change	Extension without change of a currently approved collection	2010-08-23
200707-3064-003 Approved without change	Extension without change of a currently approved collection	2007-07-18
200406-3064-001 Approved without change	Revision of a currently approved collection	2004-06-01
200403-3064-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2004-03-15
200208-3064-001 Approved without change	Extension without change of a currently approved collection	2002-08-22
199907-3064-001 Approved without change	Extension without change of a currently approved collection	1999-07-28
199606-3064-001 Approved without change	Revision of a currently approved collection	1996-06-19
199508-3064-001 Approved without change	Revision of a currently approved collection	1995-08-09
199406-3064-003 Approved without change	Revision of a currently approved collection	1994-06-01
199301-3064-001 Approved without change	Revision of a currently approved collection	1993-01-07
198912-3064-001 Approved without change	Revision of a currently approved collection	1989-12-28
198903-3064-003 Approved with change	No material or nonsubstantive change to a currently approved collection	1989-03-24
198703-3064-002 Approved without change	Extension without change of a currently approved collection	1987-03-02
198403-3064-002 Approved without change	Revision of a currently approved collection	1984-03-14
198109-3064-003 Approved without change	Revision of a currently approved collection	1981-09-24
198104-3064-057 Approved without change	Revision of a currently approved collection	1981-04-30