You should fill out this form if you have a complaint, comment, or quesƟon about a financial insƟtuƟon, financial 

product, or financial service, or the Consumer Financial ProtecƟon Bureau (CFPB). The more informaƟon you 

provide, the beƩer we will be able to understand your issue. Please fill in this form completely and mail or fax to: 

The Consumer Financial ProtecƟon Bureau 

PO Box 4503 

Iowa City, IA 52244 

Fax: 855‐237‐2392 

 Keep a copy of your completed form for your records. 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 informaƟon from this form to the company you idenƟfy. You 

 can submit informaƟon anonymously, but we may not be able to take acƟon. 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 complaint on behalf of someone else, we may need this person’s signed, wriƩen permission 

to take acƟon. Except where noted, all items refer to the consumer with the issue. 

 Review the Privacy Act Statement found on the last page of this form. 

 We cannot act as a court of law or as a lawyer on your behalf and cannot give you legal or financial advice. 

1) I have a:* Check only one. 

2) What happened?*

Describe your complaint. 

Include facts about what happened 

and any steps you have taken to 

resolve the issue. 

Share your story.*

Tell us about what happened.

Tell us your quesƟon or comment.*  

Complete Item 2 and skip to Item 19

Complaint about something that 

happened to me involving a 

financial insƟtuƟon, product, or 

service 

Alert about a financial 

insƟtuƟon, product, service, or 

pracƟce that I think the CFPB 

should look into 

Comment or QuesƟon about a 

financial insƟtuƟon, product, 

service, or pracƟce or the 

CFPB 

* Answers to these quesƟons are necessary for the CFPB to take acƟon

3) Is this about something that happened to you / someone you know?* Yes No 

4) Is this about something you observed while working for a financial insƟtuƟon or financial service provider?* 

      Employees of a bank or other consumer financial service provider may be enƟtled to 

 certain protecƟons. For more informaƟon visit www.whistleblowers.gov. If yes, skip to Item 11

Yes No 

Consumer Assistance Form 
11) I do not want the CFPB to send informaƟon about me to the company. I understand that the   

      CFPB may not be able to take acƟon.*

7) When did this happen? ____ / ____ / ________ 

8) EsƟmate the total dollar value of your loss based on what you know right now. $ ____________ 

12) Do you have a loan or account number for this product?* If yes, provide in Item 14

Don’t Know 

5) This is about:*        Check only one. 

Checking Account 

Savings Account 

CerƟficate of Deposit (CD) 

Money Market Account 

Individual ReƟrement Account (IRA) 

Deposit Products

Credit Card 

Payday Loan 

Cash Advance Loan 

Student Loan ‐ Private 

Student Loan ‐ Federal 

Credit Products

Tax Refund AnƟcipaƟon Loan 

Car / Auto Loan 

Car Title Loan 

Debt CollecƟon 

Mortgage Loan—Purchase 

Mortgage Loan—Refinance 

Mortgage/Home Loan

Home Equity Loan / Line of Credit 

Reverse Mortgage 

ACH Transfer 

ATM/Debit Card 

Checks 

Check Cashing 

Methods of Payment

Currency Exchange 

Money Order 

Prepaid Card / Stored Value Card 

Money Transmission or RemiƩance 

GiŌ Card 

Credit Counseling 

Debt Management/SeƩlement 

Financial Advisory Service

Investment Advice (not broker‐dealer)

Credit Report / Credit Score 

Credit ReporƟng

SeƩlement Service 

Subdivision/Condo Development 

Property Development

IdenƟty TheŌ

Pawn Broker 

Other: ________________________ 

Safe Deposit Box 

9) What do you think would be a fair resoluƟon of this issue?* _______________________________________ 

_________________________________________________________________________________________

6) The issue with this product or service checked above is:*____________________________________________ 

Other

InformaƟon Given to Credit 

ReporƟng Agency 

Financial Planner 

Deposit Insurance 

Consumer Leasing 

10) I want to submit anonymously. I understand the CFPB may not be able to respond or take acƟon.*  

       If yes, skip to Item 15

13) Account or Client Number: _______________________________________________ (if available)

 We use this informaƟon to determine which company you are complaining about and to help make sure the 

 company reviews the correct account. The more informaƟon you provide, the faster we are able to process 

 this form and take acƟon on this issue. 

Telephone: ________________________ 

Website: _________________________ 

14) InformaƟon about the Company *

 *Company Name: _________________________________________ 

 *Address 1: ______________________________________________ 

 Address 2: ______________________________________________ 

 *City: _______________________ *State: _____ *Zip Code: _______ Country: _________________________ 

Second Mortgage 

Yes No 

Yes No 

Yes No 

Other: ____________ 
15) Have you done any of these things to try to resolve this issue? Check all that apply and provide details below. 

Contacted company directly 

Contacted Consumer Financial ProtecƟon Bureau 

Contacted another government agency 

Hired an aƩorney 

Filed legal acƟon 

Other: _________________________________________

Provide details such as the names of any government agencies contacted, the dates contacted, any case numbers, 

contact informaƟon, current status, aƩorney contact informaƟon (if applicable), etc. 

16) I am filling out this form on behalf of:*

Myself 

Myself and Someone Else 

Someone Else 

*What is your relaƟonship to this person?_________________________________ 

COMPLETE THIS SECTION ONLY IF FILING ON BEHALF OF SOMEONE ELSE

17) Account Contact InformaƟon *  Enter the name(s) and address associated with this account. 

Please provide us with your name and contact informaƟon:

 SalutaƟon: _________ (Mr., Mrs., Ms., Dr., etc.)

*First Name: ___________________________________ 

 Middle Name: _________________________________ 

*Last Name: ___________________________________ Suffix: ________ (Jr., Sr., etc.) 

*Mailing Address: _______________________________________________________ 

*City: __________________________ *State: ______*Zip Code/APO/FPO: _________ 

*Country: ___________________________________ 

 Phone Number: ________________________ Is this a mobile phone?: 

 Email Address: ________________________________________________________ 

Phone Number: ___________________________ Is this a mobile phone?: 

Best Way to Contact: Preferred Language: ______________ 

Best Time to Contact: 

Email Address: ________________________________________________ 

Email Text Phone Mail 

8am ‐ Noon ET Noon ‐ 4pm ET 4pm ‐ 7pm ET 

18) Other Contact InformaƟon and CommunicaƟon Preferences

 SalutaƟon: _________ (Mr., Mrs., Ms., Dr., etc.) 

*First Name: ___________________________________ 

 Middle Name: _________________________________ 

*Last Name: ___________________________________ 

 Suffix: ________ (Jr., Sr., etc.) 

*Billing Address: ________________________________________________ 

*City: _______________________ *State: ______*Zip Code/APO/FPO: _________ *Country: ______________ 

SalutaƟon: _________ (Mr., Mrs., Ms., Dr., etc.) 

First Name: __________________________________ 

Middle Name: ________________________________ 

Last Name: __________________________________ 

Suffix: ________ (Jr., Sr., etc.) 

Yes No 

 Mailing Address: _______________________________________________ (if different from Billing Address) 

 City: _______________________ State: ______ Zip Code/APO/FPO: _________ Country: ______________ 

Yes No 
Privacy Act Statement

The informaƟon that you provide will permit the Consumer Financial ProtecƟon Bureau to respond to consumer complaints and 

inquiries regarding pracƟces by banks and other insƟtuƟons supervised by the Consumer Financial ProtecƟon Bureau. The informaƟon 

may be disclosed: 

 to an enƟty that is the subject of a complaint or inquiry; 

 to a court, magistrate or administraƟve tribunal in the course of a proceeding; 

 to third parƟes to the extent necessary to obtain informaƟon that is relevant to the resoluƟon of a complaint or inquiry; 

 for enforcement, statutory, and regulatory purposes; 

 to another federal or state agency or regulatory authority; 

 to a member of Congress; to the Department of JusƟce, a court, an adjudicaƟve body or administraƟve tribunal, or a party in 

liƟgaƟon; and 

 to contractors, agents, and others. 

This collecƟon of informaƟon is authorized by 12 U.S.C. § 5493, 12 C.F.R. Part 1070. 

You are not required to file a complaint or inquiry and you may withdraw your complaint or inquiry at any Ɵme. However, if you do so, 

the Consumer Financial ProtecƟon Bureau may not be able to invesƟgate your complaint or inquiry. 

NoƟce of Consumer InformaƟon CollecƟon

This is how we accept complaints. You’re not required to fill out this form if you don’t want to submit a complaint. We esƟmate that it 

takes about 7 to 10 minutes to finish compleƟng the form. Our OMB control number for this form is 3170‐0011 and expires on 

11/30/2014. Comments or suggesƟons? Email us at PRA@cfpb.gov. 

I am or was a servicemember 

I am a dependent of a servicemember 

What is the servicemember’s status? 

AcƟve 

Reserve 

NaƟonal Guard 

ReƟred 

Veteran 

What is the servicemember’s branch of service? 

Army 

Navy 

Marines 

Air Force 

Coast Guard 

Public Health Service 

NaƟonal Oceanic and 

Atmospheric AdministraƟon 

What is the servicemember’s rank? 

E1‐E4 

E5‐E7 

E8‐E9 

O1‐O3 

O4‐O6 

O7‐O10 

W01‐CW5 

 SalutaƟon: _________ (Mr., Mrs., Ms., Dr., etc.)

*First Name: ______________________________________ 

 Middle Name: ____________________________________ 

*Last Name: ______________________________________ 

 Suffix: ________ (Jr., Sr., etc.)

*Address: ________________________________________ 

*City: _____________________________ *State: ________ 

*Zip Code/APO/FPO: ___________ *Country: ____________ 

Servicemember’s Name:

COMPLETE THIS SECTION ONLY IF COMPLAINT IS FOR A SERVICEMEMBER / DEPENDENT OF A SERVICEMEMBER

20) Is this complaint for a servicemember or dependent or spouse of a servicemember? 

Are you concerned about losing your home to foreclosure?

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 have missed payments, 

 even if you believe your mortgage company is in error. 

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

 If a foreclosure sale has been scheduled, you might have received a NoƟce of Sale or Order Seƫng Sale. 

 If yes, what is the date of the scheduled foreclosure sale?  

             Please provide the exact date, if you can. This should be on the NoƟce of Sale or the Order Seƫng Sale. 

Some companies may charge homeowners a fee for services described as foreclosure defense,  

foreclosure prevenƟon, foreclosure rescue, or loss miƟgaƟon assistance. Did you hire one of  

these companies to help you avoid foreclosure? 

21) If you are compleƟng this form about a mortgage issue, please answer these quesƟons.

 ____ / ____ / ________ 

Yes No 

Yes No 

Yes No 

Yes No Don’t Know 

Yes No 

The informaƟon given is true to the best of my knowledge and belief. I understand that  

the CFPB cannot act as my lawyer, a court of law or a financial advisor.*

19) My age is ________ Prefer Not to Answer