You should fi ll out this form if you have a complaint, comment, or ques Ɵ on about a fi nancial ins Ɵ tu Ɵ on, fi nancial

product, or fi nancial service, or the Consumer Financial Protec Ɵ on Bureau (CFPB). The more informa Ɵ on you

provide, the be Ʃ er we will be able to unders tand your issue. Please fi ll in this form completely and mail or fax to:

The Consumer Financial Protec Ɵ on 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 informa Ɵ on from this form to the company you iden Ɵ fy. You

can submit informa Ɵ on anonymously, but we may not be able to take ac Ɵ on. All complaints will be used to

help the CFPB understand consumer s’ experiences and monitor providers of fi nancial products and services.

 If you are fi ling a complaint on behalf of someone else, we may need this person’s signed, wri Ʃ en permission

to take ac Ɵ on. Except where noted, all items refe r 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 fi nancial 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 ques Ɵ on or comment.*

Complete Item 2 and skip to Item 19 Complaint about something that

happened to me involving a

fi nancial ins Ɵ tu Ɵ on, product, or

service Alert about a fi nancial

ins Ɵ tu Ɵ on, product, service, or

prac Ɵ ce that I think the CFPB

should look into Comment or Ques Ɵ on about a

fi nancial ins Ɵ tu Ɵ on, product,

service, or prac Ɵ ce or the

CFPB

* Answers to these ques Ɵ ons are necessary for the CFPB to take ac Ɵ on 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 fi nancial ins Ɵ tu Ɵ on or fi nancial service provider? *

Employees of a bank or other consumer fi nancial service provider may be en Ɵ tled to

certain protec Ɵ ons. For more informa Ɵ on visit www.whistleblowers.gov

. If yes, skip to Item 11 Yes No 

# Consumer Assistance Form11) I do not want the CFPB to send informa Ɵ on about me to the company. I understand that the

CFPB may not be able to take ac Ɵ on.* 7) When did this happen? ____ / ____ / ________

8) Es Ɵ mate 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

Cer Ɵ fi cate of Deposit (CD)

Money Market Account

Individual Re Ɵ rement Account (IRA) Deposit Products

Credit Card

Payday Loan

Cash Advance Loan

Student Loan

‐ Private Student Loan

‐ Federal Credit Products

Tax Refund An Ɵ cipa Ɵ on Loan

Car / Auto Loan

Car Title Loan

Debt Collec Ɵ on

Mortgage Loan—Purchase

Mortgage Loan—Re fi nance 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 Remi Ʃ ance Gi Ō Card Credit Counseling

Debt Management/Se Ʃ lement Financial Advisory Service

Investment Advice (not broker

‐ dealer)

Credit Report / Credit Score Credit Repor Ɵ ng Se Ʃ lement Service

Subdivision/Condo Development Property Development

Iden Ɵ ty The Ō

Pawn Broker

Other: ________________________ Safe Deposit Box

9) What do you think would be a fair resolu Ɵ on of this issue?*

______________ _______________ __________

________________ ______________ ________________ ______________ ________________ _____________ 6) The issue with this product or service checked above is:*

________________ ______________ ______________ Other

Informa Ɵ on Given to Credit

Repor Ɵ ng 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 ac Ɵ on.*

If yes, skip to Item 15

13) Account or Client Number : ________________

_________________ ______________ (if available)

We use this informa Ɵ on to determine which compan y you are complaining about and to help make sure the

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

this form and take ac Ɵ on on this issue.

Telephone: ________

________________ Website: _______

__________________ 14) Informa Ɵ on about the Company *

*Company Name: _____

_____________ ____________ ___________ *Address 1: __________

_____________ ____________ ___________ Address 2: _______

____________________________ ___________ *City: _______________________ *State: _____ *Zip Code: _______ Co untry: _________

________________ 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 Protec Ɵ on Bureau

Contacted another government agency Hired an a Ʃ orney

Filed legal ac Ɵ on

Other:

_________________________________________ Provide details such as the names of any government agen cies contacted, the dates contacted, any case numbers,

contact informa Ɵ on, current status, a Ʃ orney contact informa Ɵ on (if applicable), etc.

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

Myself

Myself and Someone Else

Someone Else

*What is your rela Ɵ onship to this person?___

_________________ _____________ COMPLETE THIS SECTION ONLY IF FILING ON BEHALF OF SOMEONE ELSE

17) Account Contact Informa Ɵ on * Enter the name(s) and address associated with this account. Please provide us with your name and contact informa Ɵ on:

Saluta Ɵ on: _________ (Mr., Mrs., Ms., Dr., etc.)

*First Name: _________

________________ __________ Middle Name: _________

_______________ _________ *Last Name: ____________

_____________ __________ Su ffi x: ________ (Jr., Sr., etc.)

*Mailing Address: ____

____________________________________ _______________ *City: __________________ ________ *State: ______*Zip Code/A PO/FPO: _________

*Country: ___________

_____________ ___________ Phone Number: _______ _________________ Is th is a mobile phone?:

Email Address: ________________

________________ ______________ __________

Phone Number: _________

_______________ ___ Is this a mobile phone?:

Best Way to Contact: Preferred Langu age: ______________

Best Time to Contact:

Email Address: _________________

__________________ _____________ Email Text Phone Mail

8am

‐ Noon ET Noon

‐ 4pm ET 4pm

‐ 7pm ET 18) Other Contact Informa Ɵ on and Communica Ɵ on Preferences Saluta Ɵ on: _________ (Mr., Mrs., Ms., Dr., etc.)

*First Name: _________

________________ __________ Middle Name: _________

_______________ _________ *Last Name: ____________

_____________ __________

Su ffi x: ________ (Jr., Sr., etc.)

*Billing Address: ____

__________________ ______________ ____________ *City: _______________________ *State: ______*Zip Code/APO/FPO : _________ *Country: ______________ Saluta Ɵ on: _________ (Mr., Mrs., Ms., Dr., etc.)

First Name: _____________

__________ ___________ Middle Name: ___________

_____________ ________

Last Name: __________

________________ ________

Su ffi x: ________ (Jr., Sr., etc.)

Yes No Mailing Address:

_______________ __________________ ______________ ( if di ff

erent from Billing Address )

City: _____________ __________ State: ______ Zip Code/APO /FPO: _________ Co untry: ______________ Yes NoPrivacy Act Statement

The informa Ɵ on that you provide will permit the Consumer Financial Protec Ɵ on Bureau to respond to consumer complaints and

inquiries regarding prac Ɵ ces by banks and other ins Ɵ tu Ɵ ons supervised by the Consumer Financial Protec Ɵ on Bureau. The informa Ɵ on

may be disclosed:

 to an en Ɵ ty that is the subject of a complaint or inquiry;

 to a court, magistrate or administra Ɵ ve tribunal in the course of a proceeding;

 to third par Ɵ es to the extent necessary to obtain informa Ɵ on that is relevant to the resolu Ɵ on of a complaint or inquiry;

 for enforcement, statutory, and regulatory purposes;

 to another federal or state agen cy or regulatory authority;

 to a member of Congress; to the Department of Jus Ɵ ce, a court, an adjudica Ɵ ve body or administra Ɵ ve tribunal, or a party in

li Ɵ ga Ɵ on; and

 to contractors, agents, and others.

This collec Ɵ on of informa Ɵ on is authorized by 12 U.S.C. § 5493, 12 C.F.R. Part 1070.

You are not required to fi le a complaint or inquiry and you may withdraw your complaint or inquiry at any Ɵ me. However, if you do so,

the Consumer Financial Protec Ɵ on Bureau may not be able to inves Ɵ gate your complaint or inquiry.

No Ɵ ce of Consumer Informa Ɵ on Collec Ɵ on

This is how we accept complaints. You’re not required to fi ll out this form if you don’t want to submit a complaint. We es Ɵ mate that it

takes about 7 to 10 minutes to fi nish comple Ɵ ng the form. Our OMB control number for this form is 3170

‐ 0011 and expires on

11/30/2014 . Comments or sugges Ɵ ons? 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?

Ac Ɵ ve

Reserve

Na Ɵ onal Guard Re Ɵ red

Veteran

What is the servicemembe r’s branch of service?

Army

Navy

Marines

Air Force Coast Guard

Public Health Service

Na Ɵ onal Oceanic and

Atmospheric Administra Ɵ on

What is the servicemember’s rank?

E1

‐ E4

E5

‐ E7

E8

‐ E9 O1

‐ O3

O4

‐ O6

O7

‐ O10 W01

‐ CW5 Saluta Ɵ on: _________ (Mr., Mrs., Ms., Dr., etc.)

*First Name: ____________

_______________ ___________ Middle Name: _________

_______________ ____________ *Last Name: _______________

______________ _________

Su ffi x: ________ (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 No Ɵ ce of Sale or Order Se ƫ ng 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 No Ɵ ce of Sale or the Order Se ƫ ng Sale.

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

foreclosure preven Ɵ on, foreclosure rescue, or loss mi Ɵ ga Ɵ on assistance. Did you hire one of

these companies to help you avoid foreclosure? 21) If you are comple Ɵ ng this form about a mortgage issue, please answer these ques Ɵ ons.

____ / ____ / ________ Yes No

Yes No

Yes No

Yes No Don’t Know

Yes No



### The informa Ɵ on 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 fi nancial advisor.* 19) My age is

________ Prefer Not to Answer