### Inventory of Questions for the Consumer Financial Protection Bureau’s Consumer Response Intake Form (OMB No. 3170

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### * Answers to these questions are necessary for CFPB take action INSTRUCTIONS

You should fill out this form if you have a complaint, comment, or question about a financial institution, financial product, or financial service, or the Consumer Financial Protection Bureau (CFPB). The more information you provide, the bett er we will be able to understand your issue

.

• Once we receive your form, we will provide you with a case number. Keep this case number for

future contact with the CFPB.

• For most complaints, the CFPB forwards some information from this form to the company you identify. You can submit information anonymously, but we may not be able to take action. All complaints will be used to help the CFPB understand consumers’ experiences and monitor providers of financial products and services.

• If you are filing a compla int on behalf of someone else, we may need this person’s signed, written permission to take action. Except where noted, all questions refer to the consumer with

the issue.

• Whistleblowers who currently or have previously worked at or with a financial instit ution should contact us directly via phone or email. Learn more 1

.

• Review the Privacy Act Statement found here 2 and save or print it for your records.

• We cannot act as a court of law or as a lawyer on your behalf and cannot give you legal or

financial advi ce.

I. ABOUT THE ISSUE The “About the Issue” section is designed to capture information needed by the CFPB to investigate and respond to complaints, whistleblower complaints, comments and questions about financial institutions, financial products, or financi al services, and comments or questions about the CFPB.

1. I have a: * [CHECKBOX]

• Complaint about something that happened to me involving a financial institution, product,
or service;

• Alert about a financial institution, product, service, or practic e that I think the CFPB should look into;

1 http://www.consumerfinance.gov/blog/the

- c fpb

- wants

- you

- to

- blow

- the

- whistle

- on

- lawbreakers/

2 Privacy Act Statement quote : The information you provide will permit the Consumer Financial Protection Bureau to respond to your complaint or inquiry about companies and services we supervise. Informati on about your complaint or inquiry (including your personally identifiable information) may be shared: • with the entity that is the subject of your complaint; • with third parties as necessary to get information relevant to resolving a complaint;

• with a court, a party in litigation, a magistrate, an adjudicative body or administrative tribunal in the course of a proceeding, or the Department of Justice; • with other federal or state agencies or regulatory authorities for enforcement and statutory purpose s; and • with contractors, agents, and others authorized by the CFPB to receive this information. We may also share your complaint or inquiry (but not your personally identifiable information) with the public through a public complaint database.

This colle ction of information is authorized by 12 U.S.C. § 5493. You are not required to file a complaint or share any identifying information, including your Social Security number, and you may withdraw your complaint at any time. However, if you do not include th e requested information, the CFPB may not be able to act on your complaint.

### Inventory of Questions for the Consumer Financial Protection Bureau’s Consumer Response Intake Form (OMB No. 3170

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### * Answers to these questions are necessary for CFPB take action • Comment or Question about a financial institution, product, service, or practice or the CFPB;

Prompts for item 2, Item 6, and Item 10 are driven by the user’s selection in the web form.

2. What happened?: * [TEXT]

• Describe your complaint. Include facts about what happened and any steps you have taken to resolve the issue. ( Go to Item 3 )

• Share your story. Tell us about what happened . ( Go to Item 3 )

• Tell us your question or comment. ( Go to Item 5, Item 6, Item 1 5 , and Items 1 7 onwards )

Item 2 of the web intake form will use “natural language processing” to suggest possible products, sub

- products, issues, sub

- issues, and fair resolutions in Item 5, Item 6, and Item 9. Consumers will also have the option in the web form to “tag” key words to help the Consumer Financial Protection Bureau process their brief text description.

3. Is this about something that happened to you / someone you know? * [CHECKBOX]

4. Is this about something you observed while working fo r a financial institution or financial service provider? * [CHECKBOX] Employees of a bank or other consumer financial service provider may be entitled to certain protections. For more information visit www.whistleblowers.gov.

Item 3 and Item 4 ar e designed to identify whistleblower complaints. If “No” to Item 3 and “Yes” to Item
4, go to Item 10.

5. This is about: * Check only one. [CHECKBOX]

a. Product or Service (e.g., checking account)

b. Sub

- Product or Sub

- Service (optional) (e.g ., overdraft protection)

The web form uses “natural language processing” of the text entered in Item 2 to suggest possible products and sub

- products. Consumers have the option of checking “Other” and selecting from a dropdown menu or entering text.

Promp ts for Item 6 and Item 10 are driven by response to Item 5.

6. The issue with this product or service is: * [DROP DOWN] Please choose the issue(s) that best matches what you described.

a. Issue (e.g., charged a fee)

b. Sub

- Issue (optional) (e.g., fee higher than expected)

The web form uses “natural language processing” of the text entered in Item 2 and the response to Item 5 to suggest possible issues and sub

- issues. Consumers have the option of checking “Other” and selecting from a dropdown menu or entering text.

7. When did this happen? [DATE]

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### * Answers to these questions are necessary for CFPB take action 8. If you have suffered a loss, E e stimate the total dollar value of your loss based on what you know right

now. [NUMBER]

9. What do you think would be a fair resolution of this issue? * [TEXT ] The web form uses “natural language processing” of the text entered in Item 2 and response to Item 6 to suggest possible resolutions. Consumers have the option of checking “Other” and selecting from a dropdown menu or entering text.

10. I want to submit an onymously. I understand the CFPB may not be able to respond or take action.* If yes, skip to Item 14. [CHECKBOX]

If “Yes,” go to Item 14. Consumer will answer Items 14

- 15 and go to Submit.

11. I do not want the CFPB to send information about me to t he company. I understand the CFPB may not

be able to take action.* [CHECKBOX]

12. Do you have a loan or account number for this product? If yes, provide in Item 13. [CHECKBOX] If “No,” Item 13 is optional.

13. Account, Client Number, or other consumer identifying information for the company* [NUMBER or TEXT] We use this information to determine which company you are complaining about and to help make sure the company reviews the correct account. The more information you provide, the faster we are able to process this form and take action on this issue.

Fields in Item 13 are enabled based on relevance to product or service selected in Item 5. For most products and services, only one field is needed. Social Security Number (SSN) and Individual Taxpayer

Id entification Number (ITIN) will only be enabled for credit reporting complaints and debt collection since the consumer’s SSN or ITIN is the only unique identifying number. For debt collection complaints, only the last four of the SSN are asked.

• Custom er/Client Number

• Account Number

• Loan Number

• Mortgage Loan Number

• Mortgage Loan Originator Unique ID

• Policy Number

• Property address

• Billing address

• Transaction number

• Name and/or date of birth as appears on credit report

• Name as it appears on account • SSN o r ITIN Providing this information is optional. The CFPB only uses this information to help make sure credit reporting agencies review the correct

report.

• Credit and Prepaid Card Number The CFPB only uses your card number to ensure
we send information to the correct company. We will never ask for your expiration date or the security code on the back of your credit

card.

Checkbox to indicate when property and/or billing addresses are the same as mailing address

14. Information about the Company * [AUTO COM PLETE OR TEXT]

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### * Answers to these questions are necessary for CFPB take action W

h ere a mortgage is selected in Item 5, Item 14 will ask for “Company You Should Send Payments To: (Servicer)”.

Company Name *[AUTO COMPLETE OR TEXT], Company Type [DROP DOWN], Address [AUTO COMPLETE OR TEXT], Address 2 [AUTO COMPLETE OR TEXT], City [AUTO COMPLETE OR TEXT], State [AUTO COMPLETE OR TEXT], Zip Code [AUTO COMPLETE OR TEXT], Country [AUTO COMPLETE OR TEXT], Phone [AUTO COMPLETE OR TEXT], Website [AUTO COMPLETE OR TEXT], Email address [TEXT], Representative Name(s) or ID, Other Identifying Company Information [TEXT], Name of Mobile App [TEXT]

[OPTION TO ADD ADDITIONAL COMPANIES]

15. Have you done any of these things to try to resolve this issue? [CHECKBOX] Check all that apply and provide details below.

e.g., hired an attorney , filed a legal action; contacted the company, a government agency, the CFPB, the Better Business Bureau, etc. Also, if boxes are checked a text box will be provided to give details.

Provide details such as the names of any government agencies contacted , the dates contacted, any case numbers, contact information, current status, attorney contact information (if applicable), etc. [TEXT]

II. ABOUT THE CONSUMER This “About the Consumer” section captures information about the consumer and, where applicable, inf ormation about the individual filing the form.

16. I am filling out this form on behalf of: * [CHECKBOX]

Myself ( Go to 17) Myself and Someone Else ( Go to 18)

Someone Else If “Someone Else” is selected the following message will appear: If you are filin g on behalf of someone else, please know that the CFPB may need this person’s signed, written permission to take action on this issue. Additional instructions for sending this permission will be provided after you submit this form.

a. What is your relations hip to this person? * [CHECKBOX and TEXT] ( e.g., Family Member, Friend, Legal Client, Congressional Constituent, Advocacy Client, Community Service Organization Client, Housing Counseling Client, Other [TEXT] ) Describe your relationship to this person.* (e.g. if Advocacy Client is selected, the name of the advocacy organization)

b. Please tell us your name and contact information. Name: Salutation [DROPDOWN], First Name [TEXT]*, Middle Name [TEXT], Last Name [TEXT]*, Suffix [TEXT]

Mailing Address: Address [TEXT]*, Address 2 [TEXT], City [TEXT]*, State [TEXT]*, Zip Code/APO/FPO [TEXT]*, Country [TEXT]*

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### * Answers to these questions are necessary for CFPB take action Other Contact Information: Phone [NUMBER]*, Is this a mobile phone? [CHECKBOX]*, Fax [NUMBER], Email Address [TEXT]*

[CHECKBOX OPTION TO ADD ADDITIONAL CON TACT FIELDS]

[Checkbox option to indicate user does not have a specific piece of contact information (e.g. email)]

17. [e.g., Account] Contact Information Enter the name(s) and address associated with this [ e.g., account ].

Name [ e.g., Accountholder Name(s), Consumer Name(s), etc. ]: Salutation [DROPDOWN], First Name [TEXT]*, Middle Name [TEXT], Last Name [TEXT]*, Suffix [TEXT]

Address: Address [TEXT]*, Address 2 [TEXT], City [TEXT]*, State [TEXT]*, Zip Code/APO/FPO [TEXT]*, Country [TEXT]*, This is also the mailing address [CHECKBOX]

Other Contact Information: Phone [NUMBER]*, Is this a mobile phone? [CHECKBOX]*, Fax [NUMBER], Email Address [TEXT]*

[CHECKBOX OPTION TO ADD ADDITIONAL CONTACT FIELDS]

[Checkbox option to indicate user does not have a specific piece of contact information (e.g. email)]

18. Does this complaint involve an additional consumer? (e.g. a joint account

- holder, co

- signer, co

- borrower, an additional card holder, sender, recipient,

an additional account

- holder, etc.) 3

Mailing Information for the additional consumer Mailing Address is auto completed from Item 18 if box checked for “This is also the mailing

address”.

Name [ e.g., Accountholder Name(s), Consumer Name(s), etc. ]: Salutation [DROPDOWN], First Name [TEXT]*, Middle Name [TEXT], L ast Name [TEXT]*, Suffix [TEXT]

Address: Address [TEXT]*, Address 2 [TEXT], City [TEXT]*, State [TEXT]*, Zip Code/APO/FPO [TEXT]*, Country [TEXT]*

Other Contact Information: Phone [NUMBER]*, Is this a mobile phone? [CHECKBOX]*, Fax [NUMBER], Email Addres s [TEXT]*

Checkbox option to indicate it is the same as the complainant for jointly

- submitted complaints.

3 New question informed by usability testing under Generic Clearance for Consumer Complaint Information Collection System (Testing and Feedback), OMB Control No. 3170

- 0042 (NOA 11/ 5/2013).

### Inventory of Questions for the Consumer Financial Protection Bureau’s Consumer Response Intake Form (OMB No. 3170

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### * Answers to these questions are necessary for CFPB take action [CHECKBOX OPTION TO ADD ADDITIONAL CONTACT FIELDS]

[Checkbox option to indicate user does not have a specific piece of contact information (e.g.

em ail)]

19. Would you like to add an additional point of contact? [CHECKBOX] If user would like to add an additional point of contact, go to item 16 and complete its subparts

for this user. 4

20. Other Contact Information and Communication Preferences

Phone Number [NUMBER], Is this a mobile phone? [CHECKBOX], Alternate Phone Number [NUMBER], Is this a mobile phone? [CHECKBOX], Fax [NUMBER], Email Address [TEXT], Confirm Email Address [TEXT]

[CHECKBOX OPTION TO ADD ADDITIONAL CONTACT FIELDS]

B est Way to Contact [C HECKBOX] (e.g., email, text, phone, mail, fax), Best Time to Contact [DROPDOWN] (e.g., 8am

- Noon ET, Noon

- 4pm ET, 4pm

- 7pm ET), Preferred Language [DROPDOWN]

21. Create a Password and/or a PIN*

You can see the status of this complaint at www.consumerfinance.gov . Your username is [ Email address from Item 16

- 18 or if no email is provided a different username or unique identifier may be used to log in ]. Do not use the same password you use to log in to this ema il account. The password must include at least one capital letter and a number or special character.

Create Password [TEXT] and/or PIN [NUMBER]

22. What is your age? ______ [NUMBER]

23. What affiliations apply to the complainant? Check all that apply. [C HECKBOX]

Servicemember or veteran Dependent of a servicemember or veteran

Current student 62 years old or older A person with a disability

If servicemember or veteran or a dependent of a servicemember or veteran is selected:

Servicemember’s Na me: Salutation [DROPDOWN], First Name [TEXT]*, Middle Name [TEXT],

Last Name [TEXT]*, Suffix [TEXT]

4 Usability Testing

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### * Answers to these questions are necessary for CFPB take action Address : Is the servicemember’s address the same as mailing address already provided? [CHECKBOX], Address [TEXT]*, Address 2 [TEXT], City [TEXT]*, State [T EXT]*, Zip Code/APO/FPO [TEXT]*, Country [TEXT]*

What is the servicemember’s status? [DROP DOWN]* What is the servicemember’s branch of service? [DROP DOWN]* What is the servicemember’s rank? [DROP DOWN] What is the servicemember’s installation? [DROP DOWN]

[ CHECKBOX OPTION TO ADD ADDITIONAL SERVICEMEMBER CONTACT FIELDS]

24. If you are completing this form about a mortgage issue, please answer these questions. In the web form, Item 24 and its subparts only appear when the response to Item 5 is mortgage

r elated.

a. Are you concerned about losing your home to foreclosure? [CHECKBOX] If No, skip to Submit.

b. Have you missed any mortgage payments or are you in default on your mortgage? Also check “Yes” if your mortgage company believes you are in default or h ave missed payments, even if you believe your mortgage company is in error. [CHECKBOX] If “Yes”, continue to Item c. If “No”, skip to Item d.

c. Is there a date that is scheduled for the foreclosure sale of your home? If a foreclosure sale

has been sch eduled, you might have received a Notice of Sale or Order Setting Sale. If “Yes”, continue to Item c. [CHECKBOX] If “No” or “Don’t Know”, skip to Item d.

i. If yes, what is the date of the scheduled foreclosure sale? Please provide

the exact date if you can. This should be on the Notice of Sale or the Order Setting Sale. [DATE] [CHECKBOX]

d. Some companies may charge homeowners a fee for services described as foreclosure defense, foreclosure prevention, foreclosure rescue, or loss mitigation assistance. Did you hire one of these companies to help you avoid foreclosure? [CHECKBOX] If “Yes”, then continue to Item g. If “No” or “Don’t Know”, then skip to Submit.

e. If you hired a company to help you avoid foreclosure, what is the name of that

com pany? [TEXT]

25. If you are completing this form about a payday or consumer loan issue, please answer these questions. In the web form, Item 25 and its subparts only appear when the response to Item 5 is payday or

consumer loan

- related (e.g. title or pawn loa ns).

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### * Answers to these questions are necessary for CFPB take action a. Where did you get the payday or consumer loan? The user may indicate “In person / at a store (even if you applied online)” or “Online”

b. If “in person / at a store,” user is asked for the US state location

c. If “online,” the user is asked for the compa ny’s website

26. If you are completing this form about a credit reporting issue, please answer these questions : In the web form, Item 26 and its subparts only appear when the response to Item 5 is credit reporting or when the a credit reporting issue is selec ted in Item 6.

a. Have you disputed the issue with the credit reporting company and received a final response?

<Checkbox> <Yes or No>

b. If “YES,” what is the original dispute case number? [NUMBER]

c. I authorize and direct any credit reporting agency to furnish a copy of my consumer report to the CFPB for the purpose of responding to and investigating my consumer complaint.* [Checkbox]

d. Note, for a third party the authorization would add “ This authorization must be completed by the consumer for whom th is complaint pertains and not the consumer’s representative. Submission by anyone other than the consumer may be considered a false statement and punishable by law.”

27. If you are completing this form about a money transfer issue, please answer these questio ns : In the web form, Item 27 and its subparts only appear when the response to Item 5 is money transfer

a. Where did the transaction take place? [DROPDOWN] The user may indicate “In person, phone, fax” or “Online”

b. If “in person, phone, fax” user is then as ked for the company’s identifying information in item 14 if not previously indicated by the user

c. If “online,” the user is asked for the company’s website or name of mobile app [TEXT}

d. How much was transferred? [NUMBER]

e. What is the date of transfer? [DATE ]

f. What is the funds promised date? [DATE]

g. What was the amount of error? [NUMBER]

h. What was the date the issue occurred? [DATE] [NUMBER]

i. How was the transfer received? [DROPDOWN] (e.g. in person or home or deposited or credited into an account)

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### * Answers to these questions are necessary for CFPB take action j. For eith er option, user is then asked for the company’s identifying information in item 14 if not previously indicated by the user

28. If you are completing this form about a student loan issue, please answer these questions : In the web form, Item 28 and its subpart s only appear when the response to Item 5 is related to a

student loan.

a. What college or university did you attend when you received the loan(s)? [DROPDOWN]

29. If you are completing this form about a vehicle loan or lease issue, please answer these questions : In the web form, Item 29 and its subparts only appear when the response to Item 5 is vehicle loan or

lease

a. What is the type of vehicle? (e.g. new or use) [DROPDOWN]

b. Where did you receive your vehicle financing? (e.g. dealership, bank, lender or

financi ng company).

c. If dealership, what is the name of the dealership? [TEXT] and state [DROPDOWN]

30. Consent to Publish What Happened in the Complaint Database Information about financial products and services is collected to improve the financial products

marke tplace. The subject, date of the complaint and the company’s response may be published in the Complaint Database for researchers, journalists, and the public. All personal information, such as names, contact information, account numbers, social security nu mbers, and supporting documents

wil l be removed before publishing.

31. Security Questions* The user is asked a series of randomized security questions at the end of the complaint form for purposes of authenticating the user. This information will be used to v erify a return submitter and to grant the user future access to the complaint’s details and company’s response, including by web or phone.

32. Captcha* To prevent abuse of the complaint system by automated programs and other high

- frequency users, a captcha co nsisting of a series of randomized characters may be added in certain cases for human verification purposes.

III. SUBMIT Consumers will have an opportunity to view and edit all responses before submitting and will check a box indicating that they understand CF PB cannot act as their personal lawyer and cannot give legal advice and affirm that the information provided is true and complete to the best of their knowledge.

The information given is true to the best of my knowledge and belief. I understand that the C FPB cannot act as my lawyer, a court of law or a financial advisor. * [CHECKBOX]

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### * Answers to these questions are necessary for CFPB take action IV. DOCUMENTS [POST

- SUBMISSION, OPTIONAL AT INTAKE] If you want to attach documents to send to the company to support your complaint or to help us investigate this issue, plea se indicate how you would like to provide this documentation. Please note that because of the number of complaints we receive, we may not be able to review all the

documents submitted. [CHECKBOX]

To upload documents, attach here . If uploading documents, please provide a brief description of

the documents. [TEXT] To email documents, click here for template and email address

. To submit documents by fax, click here to download print a fax coversheet

. To submit documents by mail, click here to download and print a cover letter and for the CFPB’s complaint mailing address . Do not send original documents.

Privacy Act Statement The information that you provide will permit the Consumer Financial Protection Bureau to respond to consumer complaints and inquiries regarding practices by banks and other institutions supervised by the Consumer Financial Protection Bureau. The information may be disclosed:

• to an entity that is the subject of a complaint or inquiry;

• to a court, magistrate or administrative tribunal in the course of a proceeding;

• to third parties to the extent necessary to obtain information that is relevant to the resolution of a complaint or inquiry;

• for enforcement, statutory, and regulatory purposes;

• to another federal or state agency or regulatory a uthority;

• to a member of Congress; to the Department of Justice, a court, an adjudicative body or administrative tribunal, or a party in litigation; and

• to contractors, agents, and others.

This collection of information is authorized by 12 U.S.C. § 5493.

You are not required to file a complaint or inquiry and you may withdraw your complaint or inquiry at any time. However, if you do so, the Consumer Financial Protection Bureau may not be able to investigate your complaint or inquiry.

Notice of Consumer I nformation Collection An agency may not conduct or sponsor, and a person in not required to respond to, a collection of information unless the collection of information displays a valid control number assigned by the Office of Management and Budget (OMB)

. The OMB control number for this collection is 3170

- 0011. This collection expires on XX/XX/XXXX.

### Inventory of Questions for the Consumer Financial Protection Bureau’s Consumer Response Intake Form (OMB No. 3170

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### * Answers to these questions are necessary for CFPB take action Privacy Act Statement The information that you provide will permit the Consumer Financial Protection Bureau to respond to consumer complaints and inquir ies regarding practices by banks and other institutions supervised by the Consumer Financial Protection Bureau. The information may be disclosed:

• to an entity that is the subject of a complaint or inquiry;

• to a court, magistrate or administrative tribunal in the course of a proceeding;

• to third parties to the extent necessary to obtain information that is relevant to the resolution of a complaint or inquiry;

• for enforcement, statutory, and regulatory purposes;

• to another federal or state agency or regulato ry authority;

• to a member of Congress; to the Department of Justice, a court, an adjudicative body or administrative tribunal, or a party in litigation; and

• to contractors, agents, and others.

This collection of information is authorized by 12 U.S.C. § 54 93.

You are not required to file a complaint or inquiry and you may withdraw your complaint or inquiry at any time. However, if you do so, the Consumer Financial Protection Bureau may not be able to investigate your complaint or inquiry.

Notice of Consum er Information Collection An agency may not conduct or sponsor, and a person in not required to respond to, a collection of information unless the collection of information displays a valid control number assigned by the Office of Management and Budget ( OMB). The OMB control number for this collection is 3170

- 0011. This collection expires on XX/XX/XXXX.