### Approved for use through MM/DD/YYYY by OMB Control No. 3170

- 00 XX 

# CFPB Company Portal

Boarding Form

To allow your company access to the consumer complaints submitted against it through the

Consumer Financial Protection Bureau (CFPB) , complete the required sections of this form . The

information requested will help us to set up your company portal, provide access to the portal

for any company

- author ized individual, and to route complaints efficiently to your portal. Once

you have completed the form you may submit the form by emailing the form to:

CFPB_StakeholderSupport@cfpb.gov



# Section A: Company Information

This section is required. Please fill out the information in this section as it relates to your

company

.

1. Enter the full name of your company:



### Click here to enter text.

2. Indicate the business structure of your company :

 Corporation

 Limited Liability Company

 Partnership

 S Corporation Notice of Collection under the Privacy Act of 1974, 5 U.S.C. § 552a

As Amended ( Privacy Act Notice)

The information that you provide to the Consumer Financial Protection Bureau (CFPB) will be used to create a user account

so that you may log on to the web

- based company portal for the CFPB’s Office of Consumer Response. Account access to

the web

- based com pany portal will enable you to view complaints or inquiries filed against your company with the CFPB

and allow you to respond to the complaints or inquiries. The information you provide may be shared:

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

• for enforcement, statutory, and regulatory purposes;

• to another federal or state agency or regulatory 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

• pursuant to the CFPB’s published Privacy Act System of records notice, CFPB.005

- Consumer Response System.

We may also share the response you submit regarding your company and its business activities (but not personally

identifi able information) with the public through the Public Complaint Database.

You are not required to submit or provide any identifying information; however, if you do not include the requested

information you may not be granted access to the company portal.

Th e collection of information is authorized by Public Law III

- 203, Title X, Sections 1011, 1012, 1013 (b)(3), 1021, 1034,

codified at 12 U.S.C. 5491, 5492, 5493(b)(3), 5511, 5534.

### Approved for use through MM/DD/YYYY by OMB Control No. 3170

- 00 XX  Sole Proprietorship

3. Enter your company’s tax ID:



### Click here to enter text.

4. Enter your company’s Financial Institution Number (FIN) (if your company does not have a FIN, list “N/A”):



### Click here to enter text.

5. Plea se list your company’s URL or website:



### Click here to enter text.

6. Is this a web

- based business (a web

- based business is a business whose products or services are offered only

through the internet)?

 Yes

 No

7. Please list the mailing address of your company ’s headquarters (this should NOT be a P.O. Box):

Street Address:



### Click here to enter text. City:



### Click here to enter text.

State:



### Choose an item. Zip:



### Click here to enter text.

8. Does this address also reflect your state of incorporation or home state of business?

 Yes (If “Yes,” skip to question 11 )

 No

ANSWER THIS QUESTION ONLY IF YOU ANSWERED “No” TO QUESTION 8

9

. Please select the state of incorporation or home state of business for your company:



### Choose an item.

10

. Please list any state business licenses your company has and indicate the state for which the license is valid :

(If you need more rows than listed, please use the additional sheets at the end of the form.)

State Business License Number: State for which the license is valid:



### Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

11. Is your company or a portion of your company owned by another company, often referred to as a parent

company?

 Yes

 No

ANSWER THESE QUESTIONS ONLY IF YOU ANSWERED “Yes ” TO QUESTION 11

11 a

. Please enter the full name of your parent company:



### Click here to enter text.

11 b. Please list a point of contact (POC) for your parent company:



### Click here to enter text.

11 c

. Please list a contact phone number or email address for the POC:



### Click here to enter text.

### Approved for use through MM/DD/YYYY by OMB Control No. 3170

- 00 XX 

# Section B: Contact Information

This section is required. The authorized company officer or their designee will be the main

point of contact for the CFPB and will be the only authorized personnel to add or remove users

from the company portal maintained by the CFPB.

12. Please list the fu ll name of the authorize d officer/employee:



### Click here to enter text.

13. Please list the title of the authorized officer/employee:



### Click here to enter text.

14. Please list the phone number of the authorized officer/employee:



### Click here to enter text.

15. Please list the email of the authorized officer/employee:



### Click here to enter text.

16. If the authorized officer/employee is unavailable, please list the full name of the official designee:



### Click here to enter text.

17. Please list the email of the offici al designee:



### Click here to enter text.

18. Please list the phone number of the official designee:



### Click here to enter text.



# Section C : Portal Users Information

This section is required. The following information is needed to setup the user profiles for each

company

- authorized individual. Enter the information necessary for all users that need access

to the company portal. Please provide information on each person you designate as a user

.

19. Are the authorized officer/employee (from Section B) and desig nee, if named, the only portal users?

 Yes

 No (If “No,” please fill out the follow ing section for each portal user .)

ANSWER THESE QUESTIONS ONLY IF YOU ANSWERED “No” TO QUESTION 19

Portal User 1:

First and Last Name:



### Click here to enter text. Title/Position:



### Click here to enter text.

Phone number:



### Click here to enter text. Email:



### Click here to enter text.

Will this person need to export data into Excel or some other file?

 Yes

 No

Would you like to designate this person to submit portal servicing tickets?

 Yes

 No

Portal User 2:

First and Last Name:



### Click here to enter text. Title/Position:



### Click here to enter text.

Phone number:



### Click here to enter text. Email:



### Click here to enter text.

Will this person need to export data into Excel or some other file?

 Yes

 No

### Approved for use through MM/DD/YYYY by OMB Control No. 3170

- 00 XX Would you like to designate this person to submit portal servicing tickets?

 Yes

 No

Portal User 3:

First and Last Name:



### Click here to enter text. Title/Position:



### Click here to enter text.

Phone number:



### Click here to enter text. Email:



### Click here to enter text.

Will this person need to export data into Excel or some other file?

 Yes

 No

Would you like to designate this person to submit portal servicing t ickets?

 Yes

 No

Portal User 4:

First and Last Name:



### Click here to enter text. Title/Position:



### Click here to enter text.

Phone number:



### Click here to enter text. Email:



### Click here to enter text.

Will this person need to export data into Excel or some other file?

 Yes

 No

Would you like to designate this person to submit portal servicing tickets?

 Yes

 No

Portal User 5:

First and Last Name:



### Click here to enter text. Title/Position:



### Click here to enter text.

Phone number:



### Click here to enter text. Email:



### Click here to enter text.

Will this person need to export data into Excel or some other file?

 Yes

 No

Would you like to designate this person to submit portal servicing tickets?

 Yes

 No



# Section D : Affiliates and Subsidiaries Information

This section is required. The following information is needed to effectively route co nsumer

complaints against affiliates and subsidiaries.

20. Does your company have any affiliates or subsidiaries?

 Yes (If “Yes,” please fill out the section below for each affiliate or subsidiary

. )

 No

ANSWER THESE QUESTION ONLY IF YOU HA VE ANSWERED “Yes” TO QUESTION 20

Affiliate or Subsidiary Information:

Name of Affiliate or Subsidiary:



### Click here to enter text. Tax ID of Affiliate or Subsidiary:



### Click here to enter text.

Please list any information regarding the state business licenses for the affiliate:

### Approved for use through MM/DD/YYYY by OMB Control No. 3170

- 00 XX State Business License Number State for which it is valid Entity or individual for which it is registered



### Click here to enter text. Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text. Click here to enter text.

Affiliate or Subsidiary Information:

Name of Affiliate or Subsidiary:



### Click here to enter text. Tax ID of Affiliate or Subsidiary:



### Click here to enter text.

Please list any information regarding the state business licenses for the affiliate:

State Business License Number State for which it is valid Entity or individual for which it is registered



### Click here to enter text. Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text. Click here to enter text.

Affiliate or Subsidiary Information:

Name of Affiliate or Subsidiary:



### Click here to enter text. Tax ID of Affiliate or Subsidiary:



### Click here to enter text.

Please list any information regarding the state business licenses for the affiliate:

State Business License Number State for which it is valid Entity or individual for which it is registered



### Click here to enter text. Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text. Click here to enter text.

Affiliate or Subsidiary Information:

Name of Affiliate or Subsidiary:



### Click here to enter text. Tax ID of Affiliate or Subsidiary:



### Click here to enter text.

Please list any information regarding the state business licenses for the affiliate:

State Business License Number State for which it is valid Entity or individual for which it is registered



### Click here to enter text. Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text. Click here to enter text.

Affiliate or Subsidiary Information:

Name of Affiliate or Subsidiary:



### Click here to enter text. Tax ID of Affiliate or Subsidiary:



### Click here to enter text.

Please list any information regarding the state business licenses for the affiliate:

State Business License Number State for which it is valid Entity or individual for which it is registered



### Click here to enter text. Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text. Click here to enter text.

### Approved for use through MM/DD/YYYY by OMB Control No. 3170

- 00 XX 

# Section E : Products/Service Information

This section is required. The following information is needed to effectively route consumer

complaints against these products/services.

21. What are your compa ny’s primary product offerings (select all that apply ) ?

 Credit Cards

 Mortgages

 Bank Accounts Services

 Consumer Loans

 Private Student Loans  Payday Loans

 Credit Reporting

 Money Transfers

 Debt Collection

 Other

______________  Prepaid Cards

22. Does your company use Bank Identification Numbers (BIN) for product identification?

 Yes

 No



# Section F : Company Logo

Please attach a copy of your company’s logo/provide an electronic copy of your company’s logo.

 By checking this box, you indicate that your company grants the CFPB permission to depict on the

Consumer Complaint Intake Form your company’s logo and/or mark, for the limited purpose of prompting

consumers who file online complaints with the CFPB to accurately identify the compan y that is the subject of

their complaint. The CFPB anticipates that this use of company logos will ensure a correct match between

the consumer and the company that is the subject of their complaint and will support a more efficient

complaint handling proc ess.

If you do not check this box, the CFPB will not use your company’s logo to assist consumers with company

identification.



# Section G : Submit

 By clicking this box, you are indicating that you believe the information provided to be true to the

best of your knowledge and belief.

To submit , save this completed form and attach it in an email to CFPB_StakeholderSupport@cfpb.gov

### Approved for use through MM/DD/YYYY by OMB Control No. 3170

- 00 XX 

# For Internal Use Only

This section is for internal notes.

Revisions to Boarding Form

.

Date Revised

_______________

Reason for Revision _______________



# Additional Supplements to On

- Boarding Form

Section A. Company Information

- Supplement

24. Please list any state business licenses your company has and indicate the state for which the license is valid.

State Business License Number: State for which the license is valid:



### Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.

Click here to enter text. Click here to enter text.



### Paperwork Reduction Act Statement

We estimate it takes about 15 minutes to complete the form with enough information to provide portal access. An

agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless 

### Internal Use O nly

.

### Approved for use through MM/DD/YYYY by OMB Control No. 3170

- 00 XX 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

- 00 XX , expires 5/31/2015.

Comments regarding this collection of information, inclu ding the estimated response time, suggestions for

improving the usefulness of the information, or suggestions for reducing the burden to respond to this collection

should be submitted to Consumer Financial Protection Bureau (Attention: PRA Office), 1700 G Street NW,

Washington, DC 20552, or by email to PRA@cfpb.gov

.