## Consumer Financial Protection Bureau Information Collection Request OMB Control Number 3170

- 0011



## Web Complaint Intake Forms

• Credit Card

• Mortgage

• Bank Account or Service

• Student Loan

• Vehicle or Consumer Loan

• Credit Reporting

• Money Transfer

• Debt Collection

• Payday & Other Consumer Loans

• Prepaid

• Other Financial Services

External Party Logins

• Consumer Po rtal Login

• Company & Government Login

Feedback Intake Form

• Web Tell Your Story form

Paper Intake Forms

• Universal complaint intake form (English and Spanish)

• Debt collection complaint intake form (English and Spanish)

Phone complaint, inquiry and feedba ck intake

• Phone scriptsL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a c r e d i t c a r d c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o y o u r c r e d i t c a r d c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u

u p d a t e d o n t h e s t a t u s o f y o u r c o m p l a i n t

.

F o r c r e d i t c a r d i s s u e s a f

f e c t i n g y o u r c r e d i t r e p o r t , s u b m i t y o u r c o m p l a i n t h e r e

.

D e s c r i b e w h a t h a p p e n e d s o w e c a n u n d e r s t a n d t h e i s s u e

. . . * D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l

s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.


### T h i s i s t h e w h a t h a p p e n e d f i e l d

3 8 6 9 c h a r a c t e r s r e m a i n i n g

I w a n t t h e C F P B t o p u b l i s h t h i s d e s c r i p t i o n o n c o n s u m e r f i n a n c e

. g o v s o t h a t o t h e r s c a n l e a r n f r o m
m y e x p e r i e n c e w i t h t h i s c o m p a n y

. I u n d e r s t a n d t h a t t h e r e i s a s m a l l c h a n c e t h a t s o m e o n e m a y b e
a b l e t o i d e n t i f y m e b a s e d o n t h e i n f o r m a t i o n I ' v e i n c l u d e d

. L e a r n m o r e

.

I f y o u l o s t m o n e y , h o w m u c h m o n e y d i d y o u l o s e ? ( O p t i o n a l )
$

W h e n d i d t h i s h a p p e n ?

H a v e y o u d o n e a n y o f t h e s e t h i n g s t o t r y t o r e s o l v e t h i s i s s u e ? ( O p t i o n a l ) 1

. W h a t h a p p e n e d ? 2

. D e s i r e d

r e s o l u t i o n 3

. M y

i n f o r m a t i o n 4

. P r o d u c t

i n f o r m a t i o n 5

. R e v i e w

W h i c h o f t h e s e b e s t d e s c r i b e s y o u r i s s u e ? *
A p p l i c a t i o n p r o c e s s i n g d e l a y

( O p t i o n a l )

C o n t a c t e d t h e c o m p a n y d i r e c t l y C o n t a c t e d t h e C o n s u m e r F i n a n c i a l P r o t e c t i o n B u r e a u

p r e v i o u s l y 

### 0

3 / 1 / 2 0 1 5p r e v i o u s l y

C o n t a c t e d a n o t h e r g o v e r n m e n t

a g e n c y H i r e d a n
a t t o r n e y F i l e d l e g a l

a c t i o n

S a v e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a c r e d i t c a r d c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o y o u r c r e d i t c a r d c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u

u p d a t e d o n t h e s t a t u s o f y o u r c o m p l a i n t

.

W h a t d o y o u t h i n k w o u l d b e a f a i r r e s o l u t i o n t o y o u r i s s u e ? * D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l

s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.


### T h i s i s t h e d e s i r e d r e s o l u t i o n

3 8 7 0 c h a r a c t e r s r e m a i n i n g ✓ W h a t h a p p e n e d ? 2

. D e s i r

e d

r e s o l u t i o n 3

. M y

i n f o r m a t i o n 4

. P r o d u c t

i n f o r m a t i o n 5

. R e v i e w

S a v e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. S e l e c t b o t h b o x e s i f s u b m i t t i n g t h i s c o m p l a i n t f o r a j o i n t a c c o u n t

. S e l e c t " S o m e o n e e l s e " i f a s s i s t i n g
s o m e o n e i n s u b m i t t i n g a c o m p l a i n t

. P r o v i d e y o u r i n f o r m a t i o n u n d e r " M y c o n t a c t i n f o r m a t i o n " a n d t h e
o t h e r p e r s o n ’ s i n f o r m a t i o n u n d e r " S o m e o n e e l s e "

.
I a m s u b m i t t i n g o n b e h a l f o f 

## F i l e a c r e d i t c a r d c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o y o u r c r e d i t c a r d c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u

u p d a t e d o n t h e s t a t u s o f y o u r c o m p l a i n t

.

S u b m i t t i n g o n b e h a l f o f s o m e o n e e l s e m a y r e q u i r e s i g n e d

, w r i t t e n p e r m i s s i o n

.



### M y c o n t a c t i n f o r m a t i o n

S a l u t a t i o n ( O p t i o n a l )

S u f f i x ( O p t i o n a l )

S t a t e

U n i t e d S t a t e s



### S o m e o n e e l s e

W h a t i s y o u r r e l a t i o n s h i p t o t h i s p e r s o n ? * 

### C h o o s e

. . . ✓ W h a t h a p p e n e d ? ✓ D e s i r e d

r e s o l u t i o n 3

. M y

i n f o r m a t i o n 4

. P r o d u c t

i n f o r m a t i o n 5

. R e v i e w

M y s e l f S o m e o n e e l s e

* F i r s t n a m e *

L a s t n a m e *

M a i l i n g a d d r e s s *

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y *

Z I P c o d e *

P h o n e ( O p t i o n a l )

E m a i l * 

### F i r s t N a m e

L a s t N a m e

M a i l i n g A d d r e s s

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y

Z i p c o d e

P h o n e ( O p t i o n a l )

E m a i l

### S a l u t a t i o n ( O p t i o n a l )

S u f f i x ( O p t i o n a l )

S t a t e

U n i t e d S t a t e s

A c c o u n t H o l d e r ' s a g e i s ( O p t i o n a l )

T h e c o n s u m e r i s a s e r v i c e m e m b e r o r i s a s p o u s e o r d e p e n d e n t o f a s e r v i c e m e m b e r

. ( O p t i o n a l )

W h a t i s t h e s e r v i c e m e m b e r ' s s t a t u s ? * 

### C h o o s e

. . . W h a t i s t h e s e r v i c e ? * 

### C h o o s e

. . . W h a t i s t h e s e r v i c e m e m b e r ' s r a n k ? * 

### C h o o s e

. . . *

S e r v i c e m e m b e r D e p e n d e n t o r s p o u s e o f a
s e r v i c e m e m b e r

B a c k

C o n t i n u e F i r s t n a m e *

L a s t n a m e *

M a i l i n g a d d r e s s *

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y *

Z I P c o d e *

P h o n e ( O p t i o n a l )

E m a i l ( O p t i o n a l ) 

### F i r s t n a m e

L a s t n a m e

M a i l i n g A d d r e s s

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y

Z i p c o d e

P h o n e ( O p t i o n a l )

E m a i l ( O p t i o n a l )

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a c r e d i t c a r d c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o y o u r c r e d i t c a r d c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u

u p d a t e d o n t h e s t a t u s o f y o u r c o m p l a i n t

.



### B i l l i n g a d d r e s s

S t a t e

U n i t e d S t a t e s

F o r a c c o u n t i d e n t i f i c a t i o n o n l y

. Y o u w i l l n o t b e c h a r g e d

.



### I n f o r m a t i o n a b o u t t h e c o m p a n y

T h e c o m p a n y n a m e y o u e n t e r e d i s n o t i n o u r d a t a b a s e

. P l e a s e e n t e r i n t h e o p t i o n a l a d d r e s s i n f o r m a t i o n

.



### S t a t e ( O p t i o n a l )

U n i t e d S t a t e s ✓ W h a t h a p p e n e d ? ✓ D e s i r e d

r e s o l u t i o n ✓ M y

i n f o r m a t i o n 4

. P r

o d u c t i n f o r m a t i o n 5

. R e v i e w

B i l l i n g a d d r e s s s a m e a s m a i l i n g
a d d r e s s

.

* B i l l i n g a d d r e s s *

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y *

Z I P c o d e *

N a m e o n a c c o u n t

C r e d i t c a r d n u m b e r

C o m p a n y n a m e *

C o m p a n y a d d r e s s ( O p t i o n a l )

C i t y ( O p t i o n a l )

Z I P c o d e ( O p t i o n a l ) 

### B i l l i n g A d d r e s s

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y

Z i p C o d e

N a m e o n A c c o u n t

C r e d i t c a r d n u m b e r

C o m p a n y N a m e

C o m p a n y A d d r e s s ( O p t i o n a l )

C i t y ( O p t i o n a l )

Z i p C o d eD o n o t s u b m i t a c o m p l a i n t i f y o u d o n o t w a n t i t t o b e f o r w a r d e d t o t h e c o m p a n y y o u s e l e c t

. A l l

c o m p l a i n t s s u b m i t t e d o n t h i s s i t e w i l l b e s e n t t o t h e c o m p a n y f o r r e s p o n s e

.



### U p l o a d a n y s u p p o r t i n g d o c u m e n t s ( O p t i o n a l )

A c c o u n t a g r e e m e n t s , m o n t h l y s t a t e m e n t s , p r o o f o f p a y m e n t , e t c

.

A t t a c h d o c u m e n t s

D o c u m e n t s m u s t b e a t t a c h e d t o y o u r c o m p l a i n t b e f o r e s u b m i s s i o n

. O n c e y o u r c o m p l a i n t i s
s u b m i t t e d

, y o u w i l l n o t b e a b l e t o a d d a n y f u r t h e r d o c u m e n t a t i o n

. Y o u m a y s u b m i t a n y d o c u m e n t t o
s u p p o r t y o u r c o m p l a i n t i n a l l d i g i t a l f i l e t y p e s e x c e p t e x e c u t a b l e f i l e s (

. e x e )

. A t t a c h

B a c k C o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a c r e d i t c a r d c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o y o u r c r e d i t c a r d c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u

u p d a t e d o n t h e s t a t u s o f y o u r c o m p l a i n t

.



### W H A T H A P P E N E D [ E D I T ]

D e s c r i b e w h a t h a p p e n e d s

o w e c a n u n d e r s t a n d t h e i s s u e . . . T h i s i s t h e w h a t h a p p e n e d f i e l d
C o n s e n t t o P u b l i s h ? C o n s e n t p r o v i d e d
I s s u e A p p l i c a t i o n p r o c e s s i n g d e l a y I f y o u l o s t m o n e y , h o w m u c h m o n e y d i d y o u l o s e ? $ 0 D a t e o f i n c i d e n t 3 / 1 / 2 0 1 5
H a v e y o u d o n e a n y o f t h e s e t h i n g s t o t r y t o r e s o l v e t h i s i s s u e ?
C o n t a c t e d t h e c o m p a n y d i r e c t l y C o n t a c t e d t h e t h e C o n s u m e r F i n a n c i a l P r o t e c t i o n B u r e a u p r e v i o u s l y C o n t a c t e d a n o t h e r g o v e r n m e n t a g e n c y
H i r e d a n a t t o r n e y
F i l e d l e g a l a c t i o n



### D E S I R E D R E S O L U T I O N [ E D I T ]

W h a t d o y o u t h i n k w o u l d b e a f a i r r e s o l u t i o n t o y o u r i s s u e ? T h i s i s t h e d e s i r e d r e s o l u t i o n



### M Y I N F O R M A T I O N [ E D I T ]

C o n t a c t i n f o r m a t i o n

M a i l i n g a d d r e s s M r F i r s t N a m e L a s t N a m e J r M a i l i n g A d d r e s s A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l ) C i t y D C Z i p c o d e U n i t e d S t a t e s E m a i l E m a i l @ c f p b

. g o v P h o n e P h o n e ( O p t i o n a l )

I a m s u b m i t t i n g o n b e h a l f o

f M y s e l f S o m e o n e e l s e ✓ W h a t h a p p e n e d ? ✓ D e s i r e d

r e s o l u t i o n ✓ M y

i n f o r m a t i o n ✓ P r o d u c t

i n f o r m a t i o n 5

. R e

v i e w

### S o m e o n e e l s e

R e l a t i o n s h i p F a m i l y m e m b e r F i r s t n a m e L a s t n a m e M a i l i n g A d d r e s s A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l ) C i t y D C Z i p c o d e U n i t e d S t a t e s E m a i l E m a i l ( O p t i o n a l )
P h o n e P h o n e ( O p t i o n a l ) 

### S e r v i c e m e m b e r i n f o r m a t i o n

T h e c o n s u m e r i s a S e r v i c e m e m b e r S e r v i c e m e m b e r i n f o r m a t i o n S e r v i c e m e m b e r s t a t u s A c t i v e S e r v i c e m e m b e r b r a n c h A r m y S e r v i c e m e m b e r r a n k W 0 1

- C W 5



### P R O D U C T I N F O R M A

T I O N [ E D I T ]

B i l l i n g a d d r e s s B i l l i n g A d d r e s s A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l ) C i t y D C Z i p C o d e U n i t e d S t a t e s C r e d i t c a r d n u m b e r * * * * * * * * * * * * * * * * * *
I n f o r m a t i o n a b o u t t h e c

o m p a n y C o m p a n y N a m e C o m p a n y A d d r e s s ( O p t i o n a l ) C i t y ( O p t i o n a l ) Z i p C o d e

T h e i n f o r m a t i o n g i v e n i s t r u e t o t h e b e s t o f m y k n o w l e d g e a n d b e l i e f

. I u n d e r s t a n d t h a t t h e C F P B

c a n n o t a c t a s m y l a w y e r , a c o u r t o f l a w , o r a f i n a n c i a l a d v i s o r

.

S u b m i t

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a m o r t g a g e c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.

D e s c r i b e w h a t h a p p e n e d s o w e c a n u n d e r s t a n d t h e i s s u e

. . . * D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l

s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.


### T h i s i s t h e w h a t h a p p e n e d f i e l d

3 8 6 9 c h a r a c t e r s r e m a i n i n g

I w a n t t h e C F P B t o p u b l i s h t h i s d e s c r i p t i o n o n c o n s u m e r f i n a n c e

. g o v s o t h a t o t h e r s c a n l e a r n f r o m
m y e x p e r i e n c e w i t h t h i s c o m p a n y

. I u n d e r s t a n d t h a t t h e r e i s a s m a l l c h a n c e t h a t s o m e o n e m a y b e
a b l e t o i d e n t i f y m e b a s e d o n t h e i n f o r m a t i o n I ' v e i n c l u d e d

. L e a r n m o r e

.

W h i c h p a r t o f t h e m o r t g a g e p r o c e s s i s y o u r i s s u e r e l a t e d t o ? *

A r e y o u c o n c e r n e d a b o u t l o s i n g y o u r h o m e t o f o r e c l o s u r e ? *

P l e a s e n o t e : F i l i n g a c o m p l a i n t w i l l n o t a u t o m a t i c a l l y d e l a y o r s t o p a f o r e c l o s u r e
H a v e y o u m i s s e d a n y m o r t g a g e p a y m e n t s o r a r e y o u i n d e f a u l t o n y o u r
m o r t g a g e ? A l s o c h e c k " Y e s " i f y o u r m o r t g a g e c o m p a n y b e l i e v e s y o u a r e i n d e f a u l t o r h a v e m i s s e d p a y m e n t s , e v e n i f y o u b e l i e v e y o u r m o r t g a g e c o m p a n y i s i n e r r o r

.

I s t h e r e a d a t e s c h e d u l e d f o r t h e f o r e c l o s u r e s a l e o f y o u r h o m e ? 

### Y e s 1

. W h a t h a p p e n e d ? 2

. D e s i r e d

r e s o l u t i o n 3

. M y

i n f o r m a t i o n 4

. P r o d u c t

i n f o r m a t i o n 5

. R e v i e w

Y e s N o

Y e s N o A p p l y i n g f o r t h e l o a n A p p l i c a t i o n , o r i g i n a t o r , m o r t g a g e b r o k e r

R e c e i v i n g a c r e d i t o f

f e r C r e d i t d e c i s i o n / U n d e r w r i t i n g
S i g n i n g t h e a g r e e m e n t S e t t l e m e n t p r o c e s s a n d c o s t s M a k i n g p a y m e n t s

L o a n s e r v i c i n g , p a y m e n t s , e s c r o w a c c o u n t s

P r o b l e m s w h e n y o u a r e u n a b l e t o p a y L o a n m o d i f i c a t i o n , f o r e c l o s u r eD i d y o u p a y a c o m p a n y t o h e l p y o u a v o i d f o r e c l o s u r e ? S o m e t i m e s c a l l e d " f o r e c l o s u r e r e s c u e , " " f o r e c l o s u r e d e f e n s e , " " f o r e c l o s u r e p r e v e n t i o n , " o r " l o s s
m i t i g a t i o n a s s i s t a n c e

. " Y e s N o

M y l o a n i s a ( n ) * 

### V A m o r t g a g e

C o n t i n u e 

### 3 / 1 / 2 0 1 5 Y o u m a y f i n d t h i s d a t e o n t h e " N o t i c e o f S a l e " o r " O r d e r S e t t i n g S a l e

. " W h e n i s t h e s c h e d u l e d f o r e c l o s u r e s a l e ?

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a m o r t g a g e c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.

W h a t d o y o u t h i n k w o u l d b e a f a i r r e s o l u t i o n t o y o u r i s s u e ? * D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l

s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.


### T h i s i s t h e d e s i r e d r e s o l u t i o n f i e l d

3 8 6 4 c h a r a c t e r s r e m a i n i n g ✓ W h a t h a p p e n e d ? 2

. D e s i r

e d

r e s o l u t i o n 3

. M y

i n f o r m a t i o n 4

. P r o d u c t

i n f o r m a t i o n 5

. R e v i e w

B a c k C o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. S e l e c t b o t h b o x e s i f s u b m i t t i n g t h i s c o m p l a i n t f o r a j o i n t a c c o u n t

. S e l e c t " S o m e o n e e l s e " i f a s s i s t i n g
s o m e o n e i n s u b m i t t i n g a c o m p l a i n t

. P r o v i d e y o u r i n f o r m a t i o n u n d e r " M y c o n t a c t i n f o r m a t i o n " a n d t h e
o t h e r p e r s o n ’ s i n f o r m a t i o n u n d e r " S o m e o n e e l s e "

.
I a m s u b m i t t i n g o n b e h a l f o f 

## F i l e a m o r t g a g e c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.

S u b m i t t i n g o n b e h a l f o f s o m e o n e e l s e m a y r e q u i r e s i g n e d

, w r i t t e n p e r m i s s i o n

.



### M y c o n t a c t i n f o r m a t i o n

S a l u t a t i o n ( O p t i o n a l )

S u f f i x ( O p t i o n a l )

S t a t e

U n i t e d S t a t e s



### S o m e o n e e l s e

W h a t i s y o u r r e l a t i o n s h i p t o t h i s p e r s o n ? * 

### C h o o s e

. . . ✓ W h a t h a p p e n e d ? ✓ D e s i r e d

r e s o l u t i o n 3

. M y

i n f o r m a t i o n 4

. P r o d u c t

i n f o r m a t i o n 5

. R e v i e w

M y s e l f S o m e o n e e l s e

* F i r s t n a m e *

L a s t n a m e *

M a i l i n g a d d r e s s *

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y *

Z I P c o d e *

P h o n e ( O p t i o n a l )

E m a i l * 

### F i r s t N a m e

L a s t N a m e

M a i l i n g A d d r e s s

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y

Z i p C o d e

P h o n e ( O p t i o n a l )

E m a i l

### S a l u t a t i o n ( O p t i o n a l )

S u f f i x ( O p t i o n a l )

S t a t e

U n i t e d S t a t e s

A c c o u n t H o l d e r ' s a g e i s ( O p t i o n a l )

T h e c o n s u m e r i s a s e r v i c e m e m b e r o r i s a s p o u s e o r d e p e n d e n t o f a s e r v i c e m e m b e r

. ( O p t i o n a l )

E n t e r t h e s e r v i c e m e m b e r i n f o r m a t i o n b e l o w

.


### S a l u t a t i o n ( O p t i o n a l )

S u f f i x ( O p t i o n a l )

S t a t e

U n i t e d S t a t e s

W h a t i s t h e s e r v i c e m e m b e r ' s s t a t u s ? * 

### C h o o s e

. . . W h a t i s t h e s e r v i c e ? * *

S e r v i c e m e m b e r D e p e n d e n t o r s p o u s e o f a
s e r v i c e m e m b e r

* F i r s t n a m e *

L a s t n a m e *

M a i l i n g a d d r e s s *

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y *

Z I P c o d e *

P h o n e ( O p t i o n a l )

E m a i l ( O p t i o n a l )

F i r s t n a m e *

M i d d l e n a m e ( O p t i o n a l )

L a s t n a m e *

A d d r e s s *

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y *

Z I P c o d e * 

### F i r s t n a m e

L a s t n a m e

M a i l i n g a d d r e s s

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y

Z i p C o d e

P h o n e ( O p t i o n a l )

E m a i l ( O p t i o n a l )

F i r s t n a m e

M i d d l e n a m e ( O p t i o n a l )

L a s t n a m e

A d d r e s s

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y

Z i p C o d e

### C h o o s e

. . .

W h a t i s t h e s e r v i c e m e m b e r ' s r a n k ? * 

### C h o o s e

. . .

B a c k

C o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a m o r t g a g e c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.



### P r o p e r t y a d d r e s s

S t a t e

U n i t e d S t a t e s

F o r a c c o u n t i d e n t i f i c a t i o n o n l y



### I n f o r m a t i o n a b o u t t h e c o m p a n y

T h e c o m p a n y n a m e y o u e n t e r e d i s n o t i n o u r d a t a b a s e

. P l e a s e e n t e r i n t h e o p t i o n a l a d d r e s s i n f o r m a t i o n

.



### S t a t e ( O p t i o n a l )

U n i t e d S t a t e s

D o n o t s u b m i t a c o m p l a i n t i f y o u d o n o t w a n t i t t o b e f o r w a r d e d t o t h e c o m p a n y y o u s e l e c t

. A l l

c o m p l a i n t s s u b m i t t e d o n t h i s s i t e w i l l b e s e n t t o t h e c o m p a n y f o r r e s p o n s e

. ✓ W h a t h a p p e n e d ? ✓ D e s i r e d

r e s o l u t i o n ✓ M y

i n f o r m a t i o n 4

. P r

o d u c t i n f o r m a t i o n 5

. R e v i e w

P r o p e r t y a d d r e s s s a m e a s m a i l i n g
a d d r e s s

.

* P r o p e r t y a d d r e s s *

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y *

Z I P c o d e *

A c c o u n t / L o a n n u m b e r ( O p t i o n a l )

C o m p a n y n a m e *

C o m p a n y a d d r e s s ( O p t i o n a l )

C i t y ( O p t i o n a l )

Z I P c o d e ( O p t i o n a l ) 

### P r o p e r t y A d d r e s s

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y

Z i p C o d e

A c c o u n t / L o a n N u m b e r ( O p t i o n a l )

C o m p a n y N a m e

C o m p a n y a d d r e s s ( O p t i o n a l )

C i t y ( O p t i o n a l )

Z i p c o d e

### U p l o a d a n y s u p p o r t i n g d o c u m e n t s ( O p t i o n a l )

M o r t g a g e s t a t e m e n t s , g o o d f a i t h e s t i m a t e s , l o a n o r i g i n a t i o n d o c u m e n t s , e t c

.

A t t a c h d o c u m e n t s

D o c u m e n t s m u s t b e a t t a c h e d t o y o u r c o m p l a i n t b e f o r e s u b m i s s i o n

. O n c e y o u r c o m p l a i n t i s
s u b m i t t e d

, y o u w i l l n o t b e a b l e t o a d d a n y f u r t h e r d o c u m e n t a t i o n

. Y o u m a y s u b m i t a n y d o c u m e n t t o
s u p p o r t y o u r c o m p l a i n t i n a l l d i g i t a l f i l e t y p e s e x c e p t e x e c u t a b l e f i l e s (

. e x e )

. A t t a c h

B a c k C o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a m o r t g a g e c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.



### W H A T H A P P E N E D [ E D I T ]

D e s c r i b e w h a t h a p p e n e d s

o w e c a n u n d e r s t a n d t h e i s s u e . . . T h i s i s t h e w h a t h a p p e n e d f i e l d
C o n s e n t t o P u b l i s h ? C o n s e n t p r o v i d e d
W h i c h p a r t o f t h e m o r t g a g e p r o c e s s i s y o u r i s s u e r e l a t e d t o ?
P r o b l e m s w h e n y o u a r e u n a b l e t o p a y

A r e y o u c o n c e r n e d a b o u t l o s i n g y o u r h o m e t o f o r e c l o s u r e ? Y e s N o H a v e y o u m i s s e d a n y m o r t g a g e p a y m e n t s o r a r e y o u i n d e f a u l t o n y o u r m o r t g a g e ? Y e s N o I s t h e r e a d a t e s c h e d u l e d f o r t h e f o r e c l o s u r e s a l e o f y o u r h o m e ? Y e s W h e n i s t h e s c h e d u l e d f o r e c l o s u r e s a l e ? 3 / 1 / 2 0 1 5
D i d y o u p a y a c o m p a n y t o h e l p y

o u a v o i d f o r e c l o s u r e ? Y e s N o T h i s i s a b o u t V A m o r t g a g e



### D E S I R E D R E S O L U T I O N [ E D I T ]

W h a t d o y o u t h i n k w o u l d b e a f a i r r e s o l u t i o n t o y o u r i s s u e ? T h i s i s t h e d e s i r e d r e s o l u t i o n f i e l d



### M Y I N F O R M A T I O N [ E D I T ]

C o n t a c t i n f o r m a t i o n

M a i l i n g a d d r e s s F i r s t N a m e L a s t N a m e M a i l i n g A d d r e s s A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l ) C i t y D C Z i p C o d e U n i t e d S t a t e s E m a i l E m a i l @ c f p b

. g o v P h o n e P h o n e ( O p t i o n a l )

I a m s u b m i t t i n g o n b e h a l f o

f M y s e l f S o m e o n e e l s e 

### S o m e o n e e l s e ✓ W h a t h a p p e n e d ? ✓ D e s i r e d

r e s o l u t i o n ✓ M y

i n f o r m a t i o n ✓ P r o d u c t

i n f o r m a t i o n 5

. R e

v i e wR e l a t i o n s h i p A d v o c a t e F i r s t n a m e L a s t n a m e M a i l i n g a d d r e s s A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l ) C i t y D C Z i p C o d e U n i t e d S t a t e s E m a i l E m a i l ( O p t i o n a l )
P h o n e P h o n e ( O p t i o n a l ) 

### S e r v i c e m e m b e r i n f o r m a t i o n

D e p e n d e n t o r s p o u s e o f a s e r v i c e m e m b e r D e p e n d e n t i n f o r m a t i o n F i r s t n a m e L a s t n a m e A d d r e s s A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l ) C i t y D C Z i p C o d e U n i t e d S t a t e s S e r v i c e m e m b e r i n f o r m a t i o n S e r v i c e m e m b e r s t a t u s R e t i r e d S e r v i c e m e m b e r b r a n c h N a v y S e r v i c e m e m b e r r a n k E 5

- E 7



### P R O D U C T I N F O R M A

T I O N [ E D I T ]

P r o p e r t y a d d r e s s i s t h e s a m e a s m a i l i n g a d d r e s s

. A c c o u n t / L o a n n u m b e r * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
I n f o r m a t i o n a b o u t t h e c

o m p a n y C o m p a n y N a m e C o m p a n y a d d r e s s ( O p t i o n a l ) C i t y ( O p t i o n a l ) Z i p c o d e

T h e i n f o r m a t i o n g i v e n i s t r u e t o t h e b e s t o f m y k n o w l e d g e a n d b e l i e f

. I u n d e r s t a n d t h a t t h e C F P B

c a n n o t a c t a s m y l a w y e r , a c o u r t o f l a w , o r a f i n a n c i a l a d v i s o r

.

S u b m i t

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a b a n k a c c o u n t o r s e r v i c e c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.

D e s c r i b e w h a t h a p p e n e d s o w e c a n u n d e r s t a n d t h e i s s u e

. . . * D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l

s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.


### T h i s i s t h e w h a t h a p p e n e d f i e l d

3 8 6 9 c h a r a c t e r s r e m a i n i n g

I w a n t t h e C F P B t o p u b l i s h t h i s d e s c r i p t i o n o n c o n s u m e r f i n a n c e

. g o v s o t h a t o t h e r s c a n l e a r n f r o m
m y e x p e r i e n c e w i t h t h i s c o m p a n y

. I u n d e r s t a n d t h a t t h e r e i s a s m a l l c h a n c e t h a t s o m e o n e m a y b e
a b l e t o i d e n t i f y m e b a s e d o n t h e i n f o r m a t i o n I ' v e i n c l u d e d

. L e a r n m o r e

.

W h i c h o f t h e s e b e s t d e s c r i b e s y o u r i s s u e ? * 1

. W h a t h a p p e n e d ? 2

. D e s i r e d

r e s o l u t i o n 3

. M y

i n f o r m a t i o n 4

. P r o d u c t

i n f o r m a t i o n 5

. R e v i e w

T h i s i s a b o u t a ( n ) *
C h e c k i n g a c c o u n t

C o n f u s i n g m a r k e t i n g , d e n i a l

, d i s c l o s u r e , f e e s , c l o s u r e , a c c o u n t a c c e s s , i n t e r e s t
, s t a t e m e n t s , j o i n t

a c c o u n t s

A v a i l a b i l i t y o f d e p o s i t s , w i t h d r a w a l p r o b l e m s a n d p e n a l t i e s , u n a u t h o r i z e d t r a n s a c t i o n s , c h e c k

c a s h i n g , p a y r o l l d e p o s i t p r o b l e m s , l o s t o r m i s s i n g f u n d s , t r a n s a c t i o n h o l d s

D i s p u t e d t r a n s a c t i o n , u n a u t h o r i z e d c a r d u s e , A T M o r d e b i t c a r d f e e s , A T M p r o b l e m s

P r o b l e m s w i t h p a y m e n t s b y c h e c k

, c a r d

, p h o n e o r o n l i n e , u n a u t h o r i z e d o r f r a u d u l e n t t r a n s a c t i o n s

O v e r d r a f t f e e s , l a t e f e e s , b o u n c e d c h e c k s A c c o u n t o p e n i n g , c l o s i n g , o r m a n a g e m e n t

D e p o s i t s a n d w i t h d r a w a l s

U s i n g a d e b i t o r A T M c a r d

M a k i n g o r r e c e i v i n g p a y m e n t s

P r o b l e m s c a u s e d b y m y f u n d s b e i n g l o wC o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a b a n k a c c o u n t o r s e r v i c e c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.

W h a t d o y o u t h i n k w o u l d b e a f a i r r e s o l u t i o n t o y o u r i s s u e ? * D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l

s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.


### T h i s i s t h e d e s i r e d r e s o l u t i o n

3 8 7 0 c h a r a c t e r s r e m a i n i n g ✓ W h a t h a p p e n e d ? 2

. D e s i r

e d

r e s o l u t i o n 3

. M y

i n f o r m a t i o n 4

. P r o d u c t

i n f o r m a t i o n 5

. R e v i e w

B a c k C o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. S e l e c t b o t h b o x e s i f s u b m i t t i n g t h i s c o m p l a i n t f o r a j o i n t a c c o u n t

. S e l e c t " S o m e o n e e l s e " i f a s s i s t i n g
s o m e o n e i n s u b m i t t i n g a c o m p l a i n t

. P r o v i d e y o u r i n f o r m a t i o n u n d e r " M y c o n t a c t i n f o r m a t i o n " a n d t h e
o t h e r p e r s o n ’ s i n f o r m a t i o n u n d e r " S o m e o n e e l s e "

.
I a m s u b m i t t i n g o n b e h a l f o f 

## F i l e a b a n k a c c o u n t o r s e r v i c e c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.

S u b m i t t i n g o n b e h a l f o f s o m e o n e e l s e m a y r e q u i r e s i g n e d

, w r i t t e n p e r m i s s i o n

.



### M y c o n t a c t i n f o r m a t i o n

D r

V

S t a t e

U n i t e d S t a t e s

A c c o u n t H o l d e r ' s a g e i s ( O p t i o n a l )

T h e c o n s u m e r i s a s e r v i c e m e m b e r o r i s a s p o u s e o r d e p e n d e n t o f a s e r v i c e m e m b e r

. ( O p t i o n a l ) ✓ W h a t h a p p e n e d ? ✓ D e s i r e d

r e s o l u t i o n 3

. M y

i n f o r m a t i o n 4

. P r o d u c t

i n f o r m a t i o n 5

. R e v i e w

M y s e l f S o m e o n e e l s e

* F i r s t n a m e *

L a s t n a m e *

M a i l i n g a d d r e s s *

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y *

Z I P c o d e *

P h o n e ( O p t i o n a l )

E m a i l * 

### F i r s t n a m e

L a s t n a m e

M a i l i n g a d d r e s s

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y

Z i p C o d e

P h o n e ( O p t i o n a l )

E m a i lB a c k C o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a b a n k a c c o u n t o r s e r v i c e c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.



### B i l l i n g a d d r e s s

S t a t e

U n i t e d S t a t e s

F o r a c c o u n t i d e n t i f i c a t i o n o n l y



### I n f o r m a t i o n a b o u t t h e c o m p a n y

T h e c o m p a n y n a m e y o u e n t e r e d i s n o t i n o u r d a t a b a s e

. P l e a s e e n t e r i n t h e o p t i o n a l a d d r e s s i n f o r m a t i o n

.



### S t a t e ( O p t i o n a l )

U n i t e d S t a t e s

D o n o t s u b m i t a c o m p l a i n t i f y o u d o n o t w a n t i t t o b e f o r w a r d e d t o t h e c o m p a n y y o u s e l e c t

. A l l

c o m p l a i n t s s u b m i t t e d o n t h i s s i t e w i l l b e s e n t t o t h e c o m p a n y f o r r e s p o n s e

. ✓ W h a t h a p p e n e d ? ✓ D e s i r e d

r e s o l u t i o n ✓ M y

i n f o r m a t i o n 4

. P r

o d u c t i n f o r m a t i o n 5

. R e v i e w

B i l l i n g a d d r e s s s a m e a s m a i l i n g
a d d r e s s

.

* B i l l i n g a d d r e s s *

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y *

Z I P c o d e *

A c c o u n t n u m b e r ( O p t i o n a l )

C o m p a n y n a m e *

C o m p a n y a d d r e s s ( O p t i o n a l )

C i t y ( O p t i o n a l )

Z I P c o d e ( O p t i o n a l ) 

### B i l l i n g a d d r e s s

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y

Z i p C o d e

A c c o u n t n u m b e r ( O p t i o n a l )

C o m p a n y N a m e

C o m p a n y A d d r e s s ( O p t i o n a l )

C i t y ( O p t i o n a l )

Z i p C o d e

### U p l o a d a n y s u p p o r t i n g d o c u m e n t s ( O p t i o n a l )

M o n t h l y s t a t e m e n t s , a c c o u n t a g r e e m e n t s , p o w e r o f a t t o r n e y f o r m s , C D c e r t i f i c a t e s , e t c

.

A t t a c h d o c u m e n t s

D o c u m e n t s m u s t b e a t t a c h e d t o y o u r c o m p l a i n t b e f o r e s u b m i s s i o n

. O n c e y o u r c o m p l a i n t i s
s u b m i t t e d

, y o u w i l l n o t b e a b l e t o a d d a n y f u r t h e r d o c u m e n t a t i o n

. Y o u m a y s u b m i t a n y d o c u m e n t t o
s u p p o r t y o u r c o m p l a i n t i n a l l d i g i t a l f i l e t y p e s e x c e p t e x e c u t a b l e f i l e s (

. e x e )

. A t t a c h

B a c k C o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a b a n k a c c o u n t o r s e r v i c e c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.



### W H A T H A P P E N E D [ E D I T ]

D e s c r i b e w h a t h a p p e n e d s

o w e c a n u n d e r s t a n d t h e i s s u e . . . T h i s i s t h e w h a t h a p p e n e d f i e l d
C o n s e n t t o P u b l i s h ? C o n s e n t p r o v i d e d
P r o d u c t C h e c k i n g a c c o u n t I s s u e A c c o u n t o p e n i n g , c l o s i n g , o r m a n a g e m e n t



### D E S I R E D R E S O L U T I O N [ E D I T ]

W h a t d o y o u t h i n k w o u l d b e a f a i r r e s o l u t i o n t o y o u r i s s u e ? T h i s i s t h e d e s i r e d r e s o l u t i o n



### M Y I N F O R M A T I O N [ E D I T ]

C o n t a c t i n f o r m a t i o n

M a i l i n g a d d r e s s D r F i r s t n a m e L a s t n a m e V M a i l i n g a d d r e s s A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l ) C i t y D C Z i p C o d e U n i t e d S t a t e s E m a i l E m a i l @ c f p b

. g o v P h o n e P h o n e ( O p t i o n a l )
A g e 5 0

I a m s u b m i t t i n g o n b e h a l f o

f M y s e l f
A g e 5 0



### P R O D U C T I N F O R M A

T I O N [ E D I T ]

B i l l i n g a d d r e s s i s t h e s a m e a s m a i l i n g a d d r e s s

. ✓ W h a t h a p p e n e d ? ✓ D e s i r e d

r e s o l u t i o n ✓ M y

i n f o r m a t i o n ✓ P r o d u c t

i n f o r m a t i o n 5

. R e

v i e wA c c o u n t n u m b e r * * * * * * * * * * * * * * * * * * * * * * * * *
I n f o r m a t i o n a b o u t t h e c

o m p a n y C o m p a n y N a m e C o m p a n y A d d r e s s ( O p t i o n a l ) C i t y ( O p t i o n a l ) Z i p C o d e

T h e i n f o r m a t i o n g i v e n i s t r u e t o t h e b e s t o f m y k n o w l e d g e a n d b e l i e f

. I u n d e r s t a n d t h a t t h e C F P B

c a n n o t a c t a s m y l a w y e r , a c o u r t o f l a w , o r a f i n a n c i a l a d v i s o r

.

S u b m i t

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a s t u d e n t l o a n c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.

D e s c r i b e w h a t h a p p e n e d s o w e c a n u n d e r s t a n d t h e i s s u e

. I n c l u d e t h e n a m e a n d l o c a t i o n o f y o u r
s c h o o l

. * D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l

s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.


### T h i s i s t h e w h a t h a p p e n e d f i e l d

3 8 6 9 c h a r a c t e r s r e m a i n i n g

I w a n t t h e C F P B t o p u b l i s h t h i s d e s c r i p t i o n o n c o n s u m e r f i n a n c e

. g o v s o t h a t o t h e r s c a n l e a r n f r o m
m y e x p e r i e n c e w i t h t h i s c o m p a n y

. I u n d e r s t a n d t h a t t h e r e i s a s m a l l c h a n c e t h a t s o m e o n e m a y b e
a b l e t o i d e n t i f y m e b a s e d o n t h e i n f o r m a t i o n I ' v e i n c l u d e d

. L e a r n m o r e

.

W h i c h o f t h e s e b e s t d e s c r i b e s y o u r i s s u e ? * 1

. W h a t h a p p e n e d ? 2

. D e s i r e d

r e s o l u t i o n 3

. M y

i n f o r m a t i o n 4

. P r o d u c t

i n f o r m a t i o n 5

. R e v i e w

M y l o a n i s *

F e d e r a l l o a n ( S t a f

f o r d

, D i r e c t , c o n s o l i d a t i o n , P L U S

, P e r k i n s )

N o n

- f e d e r a l l o a n ( P r i v a t e , a l t e r n a t i v e , o t h e r s t u d e n t l o a n )

I a m n o t s u r e

D e n i a l

, c o n f u s i n g a d v e r t i s i n g o r m a r k e t i n g , s a l e s t a c t i c s o r p r e s s u r e , f i n a n c i a l a i d s e r v i c e s , r e c r u i t i n g , f r a u d u l e n t l o a n

D e f e r m e n t
, f o r b e a r a n c e , d e f a u l t
, b a n k r u p t c y , p a y m e n t p l a n , r e f i n a n c i n g G e t t i n g a l o a n

C a n ' t q u a l i f y f o r a l o a n

Q u a l i f y f o r a b e t t e r l o a n t h a n t h e o n e o f

f e r e d

C a n ' t r e p a y m y l o a nM

a k i n g p a y m e n t s , g e t t i n g i n f o r m a t i o n a b o u t m y l o a n , m a n a g i n g m y a c c o u n t

C o n t i n u e D e a l i n g w i t h m y l e n d e r o r s e r v i c e r

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a s t u d e n t l o a n c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.

W h a t d o y o u t h i n k w o u l d b e a f a i r r e s o l u t i o n t o y o u r i s s u e ? * D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l

s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.


### T h i s i s t h e d e s i r e d r e s o l u t i o n f i e l d

3 8 6 4 c h a r a c t e r s r e m a i n i n g ✓ W h a t h a p p e n e d ? 2

. D e s i r

e d

r e s o l u t i o n 3

. M y

i n f o r m a t i o n 4

. P r o d u c t

i n f o r m a t i o n 5

. R e v i e w

B a c k C o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. S e l e c t b o t h b o x e s i f s u b m i t t i n g t h i s c o m p l a i n t f o r a j o i n t a c c o u n t

. S e l e c t " S o m e o n e e l s e " i f a s s i s t i n g
s o m e o n e i n s u b m i t t i n g a c o m p l a i n t

. P r o v i d e y o u r i n f o r m a t i o n u n d e r " M y c o n t a c t i n f o r m a t i o n " a n d t h e
o t h e r p e r s o n ’ s i n f o r m a t i o n u n d e r " S o m e o n e e l s e "

.
I a m s u b m i t t i n g o n b e h a l f o f 

## F i l e a s t u d e n t l o a n c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.

S u b m i t t i n g o n b e h a l f o f s o m e o n e e l s e m a y r e q u i r e s i g n e d

, w r i t t e n p e r m i s s i o n

.



### M y c o n t a c t i n f o r m a t i o n

S a l u t a t i o n ( O p t i o n a l )

S u f f i x ( O p t i o n a l )

S t a t e

U n i t e d S t a t e s

A c c o u n t H o l d e r ' s a g e i s ( O p t i o n a l )

T h e c o n s u m e r i s a s e r v i c e m e m b e r o r i s a s p o u s e o r d e p e n d e n t o f a s e r v i c e m e m b e r

. ( O p t i o n a l ) ✓ W h a t h a p p e n e d ? ✓ D e s i r e d

r e s o l u t i o n 3

. M y

i n f o r m a t i o n 4

. P r o d u c t

i n f o r m a t i o n 5

. R e v i e w

M y s e l f S o m e o n e e l s e

* F i r s t n a m e *

L a s t n a m e *

M a i l i n g a d d r e s s *

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y *

Z I P c o d e *

P h o n e ( O p t i o n a l )

E m a i l * 

### F i r s t n a m e

L a s t n a m e

M a i l i n g a d d r e s s

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y

Z i p C o d e

P h o n e ( O p t i o n a l )

E m a i lB a c k C o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a s t u d e n t l o a n c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.



### B i l l i n g a d d r e s s

S t a t e

U n i t e d S t a t e s

F o r a c c o u n t i d e n t i f i c a t i o n o n l y



### I n f o r m a t i o n a b o u t t h e c o m p a n y

T h e c o m p a n y n a m e y o u e n t e r e d i s n o t i n o u r d a t a b a s e

. P l e a s e e n t e r i n t h e o p t i o n a l a d d r e s s i n f o r m a t i o n

.



### S t a t e ( O p t i o n a l )

U n i t e d S t a t e s

D o n o t s u b m i t a c o m p l a i n t i f y o u d o n o t w a n t i t t o b e f o r w a r d e d t o t h e c o m p a n y y o u s e l e c t

. A l l

c o m p l a i n t s s u b m i t t e d o n t h i s s i t e w i l l b e s e n t t o t h e c o m p a n y f o r r e s p o n s e

. ✓ W h a t h a p p e n e d ? ✓ D e s i r e d

r e s o l u t i o n ✓ M y

i n f o r m a t i o n 4

. P r

o d u c t i n f o r m a t i o n 5

. R e v i e w

B i l l i n g a d d r e s s s a m e a s m a i l i n g
a d d r e s s

.

* B i l l i n g a d d r e s s *

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y *

Z I P c o d e *

A c c o u n t / L o a n n u m b e r o r S S N ( O p t i o n a l )

C o m p a n y n a m e *

C o m p a n y a d d r e s s ( O p t i o n a l )

C i t y ( O p t i o n a l )

Z I P c o d e ( O p t i o n a l ) 

### B i l l i n g A d d r e s s

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y

Z i p C o d e

A c c o u n t / L o a n n u m b e r o r S S N ( O p t )

C o m p a n y N a m e

C o m p a n y a d d r e s s ( O p t i o n a l )

C i t y ( O p t i o n a l )

Z i p C o d e

### U p l o a d a n y s u p p o r t i n g d o c u m e n t s ( O p t i o n a l )

A c c o u n t a g r e e m e n t s , m o n t h l y s t a t e m e n t s , p r o o f o f p a y m e n t , e t c

.

A t t a c h d o c u m e n t s

D o c u m e n t s m u s t b e a t t a c h e d t o y o u r c o m p l a i n t b e f o r e s u b m i s s i o n

. O n c e y o u r c o m p l a i n t i s
s u b m i t t e d

, y o u w i l l n o t b e a b l e t o a d d a n y f u r t h e r d o c u m e n t a t i o n

. Y o u m a y s u b m i t a n y d o c u m e n t t o
s u p p o r t y o u r c o m p l a i n t i n a l l d i g i t a l f i l e t y p e s e x c e p t e x e c u t a b l e f i l e s (

. e x e )

. A t t a c h

B a c k C o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a s t u d e n t l o a n c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.



### W H A T H A P P E N E D [ E D I T ]

D e s c r i b e w h a t h a p p e n e d s

o w e c a n u n d e r s t a n d t h e i s s u e . . . T h i s i s t h e w h a t h a p p e n e d f i e l d
C o n s e n t t o P u b l i s h ? C o n s e n t p r o v i d e d
P r o d u c t N o n

- f e d e r a l l o a n ( P r i v a t e , a l t e r n a t i v e , o t h e r s t u d e n t l o a n )
I s s u e G e t t i n g a l o a n : C a n ' t q u a l i f

y f o r a l o a n



### D E S I R E D R E S O L U T I O N [ E D I T ]

W h a t d o y o u t h i n k w o u l d b e a f a i r r e s o l u t i o n t o y o u r i s s u e ? T h i s i s t h e d e s i r e d r e s o l u t i o n f i e l d



### M Y I N F O R M A T I O N [ E D I T ]

C o n t a c t i n f o r m a t i o n

M a i l i n g a d d r e s s F i r s t n a m e L a s t n a m e M a i l i n g a d d r e s s A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l ) C i t y D C Z i p C o d e U n i t e d S t a t e s E m a i l E m a i l @ c f p b

. g o v P h o n e P h o n e ( O p t i o n a l )

I a m s u b m i t t i n g o n b e h a l f o

f M y s e l f



### P R O D U C T I N F O R M A

T I O N [ E D I T ]

B i l l i n g a d d r e s s B i l l i n g a d d r e s s A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l ) C i t y D C Z i p C o d e U n i t e d S t a t e s ✓ W h a t h a p p e n e d ? ✓ D e s i r e d

r e s o l u t i o n ✓ M y

i n f o r m a t i o n ✓ P r o d u c t

i n f o r m a t i o n 5

. R e

v i e wA c c o u n t / L o a n n u m b e r o r S S N * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
I n f o r m a t i o n a b o u t t h e c

o m p a n y C o m p a n y N a m e C o m p a n y A d d r e s s ( O p t i o n a l ) C i t y ( O p t i o n a l )

T h e i n f o r m a t i o n g i v e n i s t r u e t o t h e b e s t o f m y k n o w l e d g e a n d b e l i e f

. I u n d e r s t a n d t h a t t h e C F P B

c a n n o t a c t a s m y l a w y e r , a c o u r t o f l a w , o r a f i n a n c i a l a d v i s o r

.

S u b m i t

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a v e h i c l e l o a n o r c o n s u m e r l o a n c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.

D e s c r i b e w h a t h a p p e n e d s o w e c a n u n d e r s t a n d t h e i s s u e

. . . * D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l

s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.


### T h i s i s t h e w h a t h a p p e n e d f i e l d

3 8 6 9 c h a r a c t e r s r e m a i n i n g

I w a n t t h e C F P B t o p u b l i s h t h i s d e s c r i p t i o n o n c o n s u m e r f i n a n c e

. g o v s o t h a t o t h e r s c a n l e a r n f r o m
m y e x p e r i e n c e w i t h t h i s c o m p a n y

. I u n d e r s t a n d t h a t t h e r e i s a s m a l l c h a n c e t h a t s o m e o n e m a y b e
a b l e t o i d e n t i f y m e b a s e d o n t h e i n f o r m a t i o n I ' v e i n c l u d e d

. L e a r n m o r e

.

W h i c h o f t h e s e b e s t d e s c r i b e s y o u r i s s u e ? * 1

. W h a t h a p p e n e d ? 2

. D e s i r e d

r e s o l u t i o n 3

. M y

i n f o r m a t i o n 4

. P r o d u c t

i n f o r m a t i o n 5

. R e v i e w

M y l o a n i s a ( n ) *
V e h i c l e l o a n

R e p o s s e s s i o n , d e f i c i e n c y , b a n k r u p t c y , d e f a u l t

S a l e s t a c t i c s o r p r e s s u r e , c r e d i t d e n i a l

, c o n f u s i n g a d v e r t i s i n g o r m a r k e t i n g

T e r m c h a n g e s ( m i d

- d e a l c h a n g e s , c h a n g e s a f t e r c l o s i n g , e t c

. )

, r e q u i r e d a d d

- o n p r o d u c t s , t r a d e

- i n p a y o f f

, f r a u d

B i l l i n g , l a t e f e e s , d a m a g e o r l o s s , i n s u r a n c e ( G A P

, c r e d i t
, e t c

. )

, p r i v a c y P r o b l e m s w h e n y o u a r e u n a b l e t o p a y

S h o p p i n g f o r a l o a n o r l e a s e

T a k i n g o u t t h e l o a n o r l e a s e

M a n a g i n g t h e l o a n o r l e a s eC o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a v e h i c l e l o a n o r c o n s u m e r l o a n c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.

W h a t d o y o u t h i n k w o u l d b e a f a i r r e s o l u t i o n t o y o u r i s s u e ? * D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l

s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.


### T h i s i s t h e d e s i r e d r e s o l u t i o n f i e l d

3 8 6 4 c h a r a c t e r s r e m a i n i n g ✓ W h a t h a p p e n e d ? 2

. D e s i r

e d

r e s o l u t i o n 3

. M y

i n f o r m a t i o n 4

. P r o d u c t

i n f o r m a t i o n 5

. R e v i e w

B a c k C o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. S e l e c t b o t h b o x e s i f s u b m i t t i n g t h i s c o m p l a i n t f o r a j o i n t a c c o u n t

. S e l e c t " S o m e o n e e l s e " i f a s s i s t i n g
s o m e o n e i n s u b m i t t i n g a c o m p l a i n t

. P r o v i d e y o u r i n f o r m a t i o n u n d e r " M y c o n t a c t i n f o r m a t i o n " a n d t h e
o t h e r p e r s o n ’ s i n f o r m a t i o n u n d e r " S o m e o n e e l s e "

.
I a m s u b m i t t i n g o n b e h a l f o f 

## F i l e a v e h i c l e l o a n o r c o n s u m e r l o a n c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.

S u b m i t t i n g o n b e h a l f o f s o m e o n e e l s e m a y r e q u i r e s i g n e d

, w r i t t e n p e r m i s s i o n

.



### M y c o n t a c t i n f o r m a t i o n

S a l u t a t i o n ( O p t i o n a l )

S u f f i x ( O p t i o n a l )

S t a t e

U n i t e d S t a t e s

A c c o u n t H o l d e r ' s a g e i s ( O p t i o n a l )

T h e c o n s u m e r i s a s e r v i c e m e m b e r o r i s a s p o u s e o r d e p e n d e n t o f a s e r v i c e m e m b e r

. ( O p t i o n a l ) ✓ W h a t h a p p e n e d ? ✓ D e s i r e d

r e s o l u t i o n 3

. M y

i n f o r m a t i o n 4

. P r o d u c t

i n f o r m a t i o n 5

. R e v i e w

M y s e l f S o m e o n e e l s e

* F i r s t n a m e *

L a s t n a m e *

M a i l i n g a d d r e s s *

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y *

Z I P c o d e *

P h o n e ( O p t i o n a l )

E m a i l * 

### F i r s t n a m e

L a s t n a m e

M a i l i n g a d d r e s s

C i t y

Z i p C o d e

P h o n e ( O p t i o n a l )

E m a i lB a c k C o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a v e h i c l e l o a n o r c o n s u m e r l o a n c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.



### B i l l i n g a d d r e s s

S t a t e

U n i t e d S t a t e s

F o r a c c o u n t i d e n t i f i c a t i o n o n l y



### I n f o r m a t i o n a b o u t t h e c o m p a n y

T h e c o m p a n y n a m e y o u e n t e r e d i s n o t i n o u r d a t a b a s e

. P l e a s e e n t e r i n t h e o p t i o n a l a d d r e s s i n f o r m a t i o n

.



### S t a t e ( O p t i o n a l )

U n i t e d S t a t e s

D o n o t s u b m i t a c o m p l a i n t i f y o u d o n o t w a n t i t t o b e f o r w a r d e d t o t h e c o m p a n y y o u s e l e c t

. A l l

c o m p l a i n t s s u b m i t t e d o n t h i s s i t e w i l l b e s e n t t o t h e c o m p a n y f o r r e s p o n s e

. ✓ W h a t h a p p e n e d ? ✓ D e s i r e d

r e s o l u t i o n ✓ M y

i n f o r m a t i o n 4

. P r

o d u c t i n f o r m a t i o n 5

. R e v i e w

B i l l i n g a d d r e s s s a m e a s m a i l i n g
a d d r e s s

.

* B i l l i n g a d d r e s s *

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y *

Z I P c o d e *

A c c o u n t / L o a n n u m b e r ( O p t i o n a l )

C o m p a n y n a m e *

C o m p a n y a d d r e s s ( O p t i o n a l )

C i t y ( O p t i o n a l )

Z I P c o d e ( O p t i o n a l ) 

### B i l l i n g a d d r e s s

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y

Z i p C o d e

A c c o u n t / L o a n n u m b e r ( O p t i o n a l )

C o m p a n y N a m e

C o m p a n y A d d r e s s ( O p t i o n a l )

C i t y ( O p t i o n a l )

Z i p C o d e

### U p l o a d a n y s u p p o r t i n g d o c u m e n t s ( O p t i o n a l )

A c c o u n t a g r e e m e n t s , m o n t h l y s t a t e m e n t s , p r o o f o f p a y m e n t , e t c

.

A t t a c h d o c u m e n t s

D o c u m e n t s m u s t b e a t t a c h e d t o y o u r c o m p l a i n t b e f o r e s u b m i s s i o n

. O n c e y o u r c o m p l a i n t i s
s u b m i t t e d

, y o u w i l l n o t b e a b l e t o a d d a n y f u r t h e r d o c u m e n t a t i o n

. Y o u m a y s u b m i t a n y d o c u m e n t t o
s u p p o r t y o u r c o m p l a i n t i n a l l d i g i t a l f i l e t y p e s e x c e p t e x e c u t a b l e f i l e s (

. e x e )

. A t t a c h

B a c k C o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a v e h i c l e l o a n o r c o n s u m e r l o a n c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.



### W H A T H A P P E N E D [ E D I T ]

D e s c r i b e w h a t h a p p e n e d s

o w e c a n u n d e r s t a n d t h e i s s u e . . . T h i s i s t h e w h a t h a p p e n e d f i e l d
C o n s e n t t o P u b l i s h ? C o n s e n t p r o v i d e d
P r o d u c t V e h i c l e l o a n I s s u e S h o p p i n g f o r a l o a n o r l e a s e



### D E S I R E D R E S O L U T I O N [ E D I T ]

W h a t d o y o u t h i n k w o u l d b e a f a i r r e s o l u t i o n t o y o u r i s s u e ? T h i s i s t h e d e s i r e d r e s o l u t i o n f i e l d



### M Y I N F O R M A T I O N [ E D I T ]

C o n t a c t i n f o r m a t i o n

M a i l i n g a d d r e s s F i r s t n a m e L a s t n a m e M a i l i n g a d d r e s s C i t y D C Z i p C o d e U n i t e d S t a t e s E m a i l E m a i l @ c f p b

. g o v P h o n e P h o n e ( O p t i o n a l )
A g e 5 0

I a m s u b m i t t i n g o n b e h a l f o

f M y s e l f
A g e 5 0



### P R O D U C T I N F O R M A

T I O N [ E D I T ]

A c c o u n t n u m b e r * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
I n f o r m a t i o n a b o u t t h e c

o m p a n y ✓ W h a t h a p p e n e d ? ✓ D e s i r e d

r e s o l u t i o n ✓ M y

i n f o r m a t i o n ✓ P r o d u c t

i n f o r m a t i o n 5

. R e

v i e wC o m p a n y N a m e C o m p a n y A d d r e s s ( O p t i o n a l ) C i t y ( O p t i o n a l ) Z i p C o d e

T h e i n f o r m a t i o n g i v e n i s t r u e t o t h e b e s t o f m y k n o w l e d g e a n d b e l i e f

. I u n d e r s t a n d t h a t t h e C F P B

c a n n o t a c t a s m y l a w y e r , a c o u r t o f l a w , o r a f i n a n c i a l a d v i s o r

.

S u b m i t

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a c r e d i t r e p o r t i n g c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.

W h i c h o f t h e s e b e s t d e s c r i b e s y o u r i s s u e ? *

I n c o r r e c t i n f o r m a t i o n o n m y c r e d i t r e p o r t

I n f o r m a t i o n i s n o t m i n e B e l o n g s t o s o m e o n e e l s e , i d e n t i t y t h e f t
, f r a u d

, e t c

.

A c c o u n t t e r m s C r e d i t o r n a m e / i n f o , b a l a n c e , p a y m e n t
, e t c

.

A c c o u n t s t a t u s P a i d b i l l o n t i m e , a c c o u n t c l o s e d

, e t c

.

P e r s o n a l i n f o r m a t i o n W r o n g d a t e o f b i r t h

, a d d r e s s , e t c

.

P u b l i c r e c o r d B a n k r u p t c y , j u d g m e n t
, e t c

.

R e i n s e r t e d p r e v i o u s l y d e l e t e d i n f o r m a t i o n

C r e d i t R e p o r t i n g c o m p a n y ' s i n v e s t i g a t i o n

I m p r o p e r u s e o f m y c r e d i t r e p o r t

U n a b l e t o g e t m y c r e d i t r e p o r t o r c r e d i t s c o r e

C r e d i t m o n i t o r i n g o r i d e n t i t y p r o t e c t i o n s e r v i c e s



### H a v e y o u d i s p u t e d t h e i s s u e w i t h t h e c r e d i t r e p o r t i n g c o m p a n y a n d

r e c e i v e d a f i n a l r e s p o n s e ?

O r i g i n a l d i s p u t e c a s e n u m b e r ( O p t i o n a l ) 1

. W h a t h a p p e n e d ? 2

. P r o d u c t

i n f o r m a t i o n 3

. D e s i r e d

r e s o l u t i o n 4

. C o n s u m e r

i n f o r m a t i o n 5

. R e v i e w

Y e s N oD e s c r i b e w h a t h a p p e n e d s o w e c a n u n d e r s t a n d t h e i s s u e

. * D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l

s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.


### T h i s i s t h e w h a t h a p p e n e d f i e l d

3 8 6 9 c h a r a c t e r s r e m a i n i n g

I w a n t t h e C F P B t o p u b l i s h t h i s d e s c r i p t i o n o n c o n s u m e r f i n a n c e

. g o v s o t h a t o t h e r s c a n l e a r n f r o m
m y e x p e r i e n c e w i t h t h i s c o m p a n y

. I u n d e r s t a n d t h a t t h e r e i s a s m a l l c h a n c e t h a t s o m e o n e m a y b e
a b l e t o i d e n t i f y m e b a s e d o n t h e i n f o r m a t i o n I ' v e i n c l u d e d

. L e a r n m o r e

.



### U p l o a d a n y s u p p o r t i n g d o c u m e n t s ( O p t i o n a l )

I n c o r r e c t p a r t o f c r e d i t r e p o r t s , p a y m e n t r e c o r d s , c a n c e l l e d c h e c k s , c o u r t d o c u m e n t s , b i r t h

c e r t i f i c a t e s o r o t h e r i d e n t i t y v e r i f i c a t i o n d o c u m e n t s , c o p y o f c r e d i t r e p o r t i n g c o m p a n y ' s i n v e s t i g a t i o n

A t t a c h d o c u m e n t s

A t t a c h

C o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

.

S o c i a l S e c u r i t y n u m b e r ( O p t i o n a l )

D a t e o f b i r t h ( O p t i o n a l )

N a m e o n c r e d i t r e p o r t ( O p t i o n a l ) 

## F i l e a c r e d i t r e p o r t i n g c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.



### I n f o r m a t i o n a b o u t t h e c r e d i t r e p o r t i n g c o m p a n y

T h e c o m p a n y n a m e y o u e n t e r e d i s n o t l i s t e d i n o u r d a t a b a s e a s a c r e d i t r e p o r t i n g c o m p a n y

. P l e a s e e n t e r t h e o p t i o n a l a d d r e s s i n f o r m a t i o n

.



### S t a t e ( O p t i o n a l )

U n i t e d S t a t e s

D o n o t s u b m i t a c o m p l a i n t i f y o u d o n o t w a n t i t t o b e f o r w a r d e d t o t h e c o m p a n y y o u s e l e c t

. A l l

c o m p l a i n t s s u b m i t t e d o n t h i s s i t e w i l l b e s e n t t o t h e c o m p a n y f o r r e s p o n s e

.



### A c c o u n t i d e n t i f i c a t i o n i n f o r m a t i o n

W e n e e d t h i s i n f o r m a t i o n t o m a k e s u r e t h e c r e d i t r e p o r t i n g c o m p a n y i s a b l e t o f i n d y o u r f i l e

. W i t h o u t i t
, w e m a y n o t b e a b l e t o h e l p

. ✓ W h a t h a p p e n e d ? 2

. P r

o d u c t i n f o r m a t i o n 3

. D e s i r e d

r e s o l u t i o n 4

. C o n s u m e r

i n f o r m a t i o n 5

. R e v i e w

B a c k C o n t i n u e C o m p a n y n a m e *

C o m p a n y a d d r e s s ( O p t i o n a l )

C i t y ( O p t i o n a l )

Z I P c o d e ( O p t i o n a l )

X X X

- X X

- X X X X

M M / D D / Y Y Y Y

F i r s t m i d d l e l a s t 

### C o m p a n y N a m e

C o m p a n y A d d r e s s

C i t y

Z i p C o d eO M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a c r e d i t r e p o r t i n g c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.

W h a t d o y o u t h i n k w o u l d b e a f a i r r e s o l u t i o n t o y o u r i s s u e ? * D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l

s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.


### T h i s i s t h e d e s i r e d r e s o l u t i o n f i e l d

3 8 6 4 c h a r a c t e r s r e m a i n i n g ✓ W h a t h a p p e n e d ? ✓ P r o d u c t

i n f o r m a t i o n 3

. D e s i r

e d

r e s o l u t i o n 4

. C o n s u m e r

i n f o r m a t i o n 5

. R e v i e w

B a c k C o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. S e l e c t " S o m e o n e e l s e " i f a s s i s t i n g s o m e o n e i n s u b m i t t i n g a c o m p l a i n t

. P r o v i d e y o u r i n f o r m a t i o n
u n d e r " M y c o n t a c t i n f o r m a t i o n " a n d t h e o t h e r p e r s o n ’ s i n f o r m a t i o n u n d e r " S o m e o n e e l s e "

.
I a m s u b m i t t i n g o n b e h a l f o f 

## F i l e a c r e d i t r e p o r t i n g c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.

S u b m i t t i n g o n b e h a l f o f s o m e o n e e l s e m a y r e q u i r e s i g n e d

, w r i t t e n p e r m i s s i o n

.



### M y c o n t a c t i n f o r m a t i o n

S a l u t a t i o n ( O p t i o n a l )

S u f f i x ( O p t i o n a l )

S t a t e

U n i t e d S t a t e s

A c c o u n t H o l d e r ' s a g e i s ( O p t i o n a l ) ✓ W h a t h a p p e n e d ? ✓ P r o d u c t

i n f o r m a t i o n ✓ D e s i r e d

r e s o l u t i o n 4

. C o n s u m e r

i n f o r m a t i o n 5

. R e v i e w

M y s e l f S o m e o n e e l s e

* F i r s t n a m e *

M i d d l e n a m e ( O p t i o n a l )

L a s t n a m e *

M a i l i n g a d d r e s s *

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y *

Z I P c o d e *

P h o n e ( O p t i o n a l )

E m a i l * 

### F i r s t N a m e

M i d d l e N a m e ( O p t i o n a l )

L a s t N a m e

M a i l i n g A d d r e s s

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y

Z i p C o d e

P h o n e ( O p t i o n a l )

E m a i lT h e c o n s u m e r i s a s e r v i c e m e m b e r o r i s a s p o u s e o r d e p e n d e n t o f a s e r v i c e m e m b e r

. ( O p t i o n a l )

B a c k C o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a c r e d i t r e p o r t i n g c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.



### W H A T H A P P E N E D [ E D I T ]

I s s u e I n c o r r e c t i n f o r m a t i o n o n m y c r e d i t r e p o r t : I n f o r m a t i o n i s n o t m i n e D e s c r i b e w h a t h a p p e n e d s

o w e c a n u n d e r s t a n d t h e i s s u e . . . T h i s i s t h e w h a t h a p p e n e d f i e l d
C o n s e n t t o P u b l i s h ? C o n s e n t p r o v i d e d



### P R O D U C T I N F O R M A

T I O N [ E D I T ]

I n f o r m a t i o n a b o u t t h e c r

e d i t r e p o r t i n g c o m p a n y C o m p a n y N a m e C o m p a n y A d d r e s s C i t y Z i p C o d e



### D E S I R E D R E S O L U T I O N [ E D I T ]

W h a t d o y o u t h i n k w o u l d b e a f a i r r e s o l u t i o n t o y o u r i s s u e ? T h i s i s t h e d e s i r e d r e s o l u t i o n f i e l d



### C O N S U M E R I N F O R M A

T I O N [ E D I T ]

C o n t a c t i n f o r m a t i o n

M a i l i n g a d d r e s s F i r s t N a m e M i d d l e N a m e ( O p t i o n a l ) L a s t N a m e M a i l i n g A d d r e s s A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l ) C i t y D C Z i p C o d e U n i t e d S t a t e s E m a i l E m a i l @ c f p b

. g o v P h o n e P h o n e ( O p t i o n a l )

I a m s u b m i t t i n g o n b e h a l f o

f M y s e l f ✓ W h a t h a p p e n e d ? ✓ P r o d u c t

i n f o r m a t i o n ✓ D e s i r e d

r e s o l u t i o n ✓ C o n s u m e r

i n f o r m a t i o n 5

. R e

v i e wI a u t h o r i z e a n d d i r e c t a n y c o n s u m e r r e p o r t i n g a g e n c y t o f u r n i s h a c o p y o f m y c o n s u m e r r e p o r t t o t h e C F P B f o r t h e p u r p o s e o f r e s p o n d i n g t o a n d i n v e s t i g a t i n g m y c o n s u m e r c o m p l a i n t

.

T h e i n f o r m a t i o n g i v e n i s t r u e t o t h e b e s t o f m y k n o w l e d g e a n d b e l i e f

. I u n d e r s t a n d t h a t t h e C F P B

c a n n o t a c t a s m y l a w y e r , a c o u r t o f l a w , o r a f i n a n c i a l a d v i s o r

.

S u b m i t

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a m o n e y t r a n s f e r c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.

D e s c r i b e w h a t h a p p e n e d s o w e c a n u n d e r s t a n d t h e i s s u e

. * D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l

s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.


### T h i s i s t h e w h a t h a p p e n e d f i e l d

3 8 6 9 c h a r a c t e r s r e m a i n i n g

I w a n t t h e C F P B t o p u b l i s h t h i s d e s c r i p t i o n o n c o n s u m e r f i n a n c e

. g o v s o t h a t o t h e r s c a n l e a r n f r o m
m y e x p e r i e n c e w i t h t h i s c o m p a n y

. I u n d e r s t a n d t h a t t h e r e i s a s m a l l c h a n c e t h a t s o m e o n e m a y b e
a b l e t o i d e n t i f y m e b a s e d o n t h e i n f o r m a t i o n I ' v e i n c l u d e d

. L e a r n m o r e

.

W h i c h o f t h e s e b e s t d e s c r i b e s y o u r i s s u e ? * 1

. W h a t h a p p e n e d ? 2

. D e s i r e d

r e s o l u t i o n 3

. M y

i n f o r m a t i o n 4

. P r o d u c t

i n f o r m a t i o n 5

. R e v i e w

T h i s i s a b o u t a ( n ) *
D o m e s t i c ( U S ) m o n e y t r a n s f e r

T r a n s f e r a m o u n t s , f e e s , e x c h a n g e r a t e s , t a x e s , e t c

.

U n a u t h o r i z e d t r a n s a c t i o n , c a n c e l l a t i o n , r e f u n d

, e t c

.

A d v e r t i s i n g o r m a r k e t i n g , p r i c i n g , p r i v a c y , e t c

. M o n e y w a s n o t a v a i l a b l e w h e n p r o m i s e d

W r o n g a m o u n t c h a r g e d o r r e c e i v e d

I n c o r r e c t / m i s s i n g d i s c l o s u r e s o r i n f o

O t h e r t r a n s a c t i o n i s s u e s

O t h e r s e r v i c e i s s u e s

F r a u d o r s c a mC o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a m o n e y t r a n s f e r c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.

W h a t d o y o u t h i n k w o u l d b e a f a i r r e s o l u t i o n t o y o u r i s s u e ? * D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l

s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.


### T h i s i s t h e d e s i r e d r e s o l u t i o n

3 8 7 0 c h a r a c t e r s r e m a i n i n g ✓ W h a t h a p p e n e d ? 2

. D e s i r

e d

r e s o l u t i o n 3

. M y

i n f o r m a t i o n 4

. P r o d u c t

i n f o r m a t i o n 5

. R e v i e w

B a c k C o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. I a m ( t h e )

S e l e c t b o t h b o x e s i f s u b m i t t i n g t h i s c o m p l a i n t f o r a j o i n t a c c o u n t

. S e l e c t " S o m e o n e e l s e " i f a s s i s t i n g
s o m e o n e i n s u b m i t t i n g a c o m p l a i n t

. P r o v i d e y o u r i n f o r m a t i o n u n d e r " M y c o n t a c t i n f o r m a t i o n " a n d t h e
o t h e r p e r s o n ’ s i n f o r m a t i o n u n d e r " S o m e o n e e l s e "

.

I a m s u b m i t t i n g o n b e h a l f o f 

## F i l e a m o n e y t r a n s f e r c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.

S u b m i t t i n g o n b e h a l f o f s o m e o n e e l s e m a y r e q u i r e s i g n e d

, w r i t t e n p e r m i s s i o n

.



### M y c o n t a c t i n f o r m a t i o n

S a l u t a t i o n ( O p t i o n a l )

S u f f i x ( O p t i o n a l )

U n i t e d S t a t e s

S t a t e

A c c o u n t H o l d e r ' s a g e i s ( O p t i o n a l ) ✓ W h a t h a p p e n e d ? ✓ D e s i r e d

r e s o l u t i o n 3

. M y

i n f o r m a t i o n 4

. P r o d u c t

i n f o r m a t i o n 5

. R e v i e w

S e n d e r R e c i p i e n t F i l i n g o n b e h a l f o f s o m e o n e e l s e

M y s e l f S o m e o n e e l s e

* F i r s t n a m e *

M i d d l e n a m e ( O p t i o n a l )

L a s t n a m e *

M a i l i n g a d d r e s s *

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y *

Z I P c o d e *

P h o n e ( O p t i o n a l )

E m a i l * 

### F i r s t n a m e

M i d d l e n a m e ( O p t i o n a l )

L a s t n a m e

M a i l i n g a d d r e s s

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y

Z i p C o d e

P h o n e ( O p t i o n a l )

E m a i lS u b m i t t i n g o n b e h a l f o f s o m e o n e e l s e m a y r e q u i r e s i g n e d

, w r i t t e n p e r m i s s i o n

.

T h e c o n s u m e r i s a s e r v i c e m e m b e r o r i s a s p o u s e o r d e p e n d e n t o f a s e r v i c e m e m b e r

. ( O p t i o n a l )

B a c k C o n t i n u e

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a m o n e y t r a n s f e r c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.



### W h a t c o m p a n y w a s u s e d t o s e n d t h e m o n e y ?

C o m p a n y n a m e o n t h e r e c e i p t

T h e c o m p a n y n a m e y o u e n t e r e d i s n o t i n o u r d a t a b a s e

. P l e a s e e n t e r i n t h e o p t i o n a l a d d r e s s i n f o r m a t i o n

.



### S t a t e ( O p t i o n a l )

U n i t e d S t a t e s

D o n o t s u b m i t a c o m p l a i n t i f y o u d o n o t w a n t i t t o b e f o r w a r d e d t o t h e c o m p a n y y o u s e l e c t

. A l l

c o m p l a i n t s s u b m i t t e d o n t h i s s i t e w i l l b e s e n t t o t h e c o m p a n y f o r r e s p o n s e

.

A c c o u n t n u m b e r a s s o c i a t e d w i t h t h e c o m p a n y u s e d f o r t h i s t r a n s f e r

W h e r e d i d t h e t r a n s a c t i o n t a k e p l a c e ? ( O p t i o n a l ) 

### O n l i n e

S e n d e r I n f o r m a t i o n

S a l u t a t i o n ( O p t i o n a l )

S u f f i x ( O p t i o n a l ) ✓ W h a t h a p p e n e d ? ✓ D e s i r e d

r e s o l u t i o n ✓ M y

i n f o r m a t i o n 4

. P r

o d u c t i n f o r m a t i o n 5

. R e v i e w

C o m p a n y n a m e *

C o m p a n y a d d r e s s ( O p t i o n a l )

C i t y ( O p t i o n a l )

Z I P c o d e ( O p t i o n a l )

A c c o u n t n u m b e r ( O p t i o n a l )

W e b s i t e o r n a m e o f m o b i l e a p p ( O p t i o n a l )

F i r s t n a m e *

M i d d l e n a m e ( O p t i o n a l )

L a s t n a m e * 

### C o m p a n y n a m e

C o m p a n y A d d r e s s

C i t y

Z i p C o d e

A c c o u n t n u m b e r ( O p t i o n a l )

W e b s i t e o r n a m e o f m o b i l e a p p ( O p t i o n a l )

F i r s t n a m e

M i d d l e n a m e ( O p t i o n a l )

L a s t n a m e

### U S D U n i t e d S t a t e s D o l l a r

U S D U n i t e d S t a t e s D o l l a r U n i t e d S t a t e s

S t a t e

H o w m u c h w a s t r a n s f e r r e d ? ( O p t i o n a l )

D a t e o f t r a n s f e r ( O p t i o n a l )

W h a t i s t h e t r a n s f e r I D o r t r a n s a c t i o n n u m b e r ? ( O p t i o n a l ) T r a n s a c t i o n n u m b e r o r t r a n s f e r I D m a y b e f o u n d o n m o n e y t r a n s f e r r e c e i p t

F u n d s p r o m i s e d d a t e ( O p t i o n a l )

A m o u n t o f e r r o r ( O p t i o n a l )

D a t e i s s u e o c c u r r e d ( O p t i o n a l )



### P e r s o n r e c e i v i n g f u n d s

H o w w a s t h e t r a n s f e r r e c e i v e d ? ( O p t i o n a l ) 

### D e p o s i t e d o r c r e d i t e d t o a n a c c o u n t

U n i t e d S t a t e s *

A m o u n t m u s t b e i n 0

. 0 0 f o r m a t

W h e n m o n e y w a s s e n t

W h e n f u n d s e x p e c t e d

A

m o u n t m u s t b e i n 0

. 0 0 f o r m a t

W h e n e r r o r w a s f o u n d M a i l i n g a d d r e s s ( O p t i o n a l )

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y ( O p t i o n a l )

Z I P c o d e ( O p t i o n a l )

P h o n e ( O p t i o n a l )

E m a i l ( O p t i o n a l )

0

. 0 0

I D o r n u m b e r

0

. 0 0

C o m p a n y n a m e * 

### M a i l i n g a d d r e s s ( O p t i o n a l )

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y ( O p t i o n a l )

Z i p c o d e

P h o n e ( O p t i o n a l )

E m a i l ( O p t i o n a l )

0

. 0 0

I D o r n u m b e r

0

. 0 0

C o m p a n y n a m e 3 / 1 / 2 0 1 5

3 / 3 1 / 2 0 1 5

3 / 1 / 2 0 1 5

### S t a t e

A c c o u n t n u m b e r a s s o c i a t e d w i t h t h e c o m p a n y t h a t r e c e i v e d t h i s t r a n s f e r



### S a l u t a t i o n ( O p t i o n a l )

S u f f i x ( O p t i o n a l )

U n i t e d S t a t e s

S t a t e



### U p l o a d a n y s u p p o r t i n g d o c u m e n t s ( O p t i o n a l )

C o p i e s o f r e c e i p t s , d i s c l o s u r e s p r o v i d e d f o r t r a n s a c t i o n , a c c o u n t s t a t e m e n t s , a d v e r t i s e m e n t s / m a r k e t i n g l e t t e r s , e t c

.

A t t a c h d o c u m e n t s *

*

A t t a c h

B a c k C o n t i n u e C o m p a n y a d d r e s s ( O p t i o n a l )

C i t y ( O p t i o n a l )

Z I P c o d e ( O p t i o n a l )

W e b s i t e o r n a m e o f m o b i l e a p p ( O p t i o n a l )

A c c o u n t n u m b e r ( O p t i o n a l )

F i r s t n a m e *

M i d d l e n a m e ( O p t i o n a l )

L a s t n a m e *

M a i l i n g a d d r e s s ( O p t i o n a l )

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y ( O p t i o n a l )

Z I P c o d e ( O p t i o n a l )

P h o n e ( O p t i o n a l )

E m a i l ( O p t i o n a l ) 

### C o m p a n y a d d r e s s ( O p t i o n a l )

C i t y ( O p t i o n a l )

Z i p c o d e

W e b s i t e o r n a m e o f m o b i l e a p p ( O p t i o n a l )

A c c o u n t n u m b e r ( O p t i o n a l )

F i r s t n a m e

M i d d l e n a m e ( O p t i o n a l )

L a s t n a m e

M a i l i n g a d d r e s s ( O p t i o n a l )

A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l )

C i t y ( O p t i o n a l )

Z i p C o d e

P h o n e ( O p t i o n a l )

E m a i l ( O p t i o n a l )

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tL o g I n

F o r m t r o u b l e ? C h a t n o w

. 

## F i l e a m o n e y t r a n s f e r c o m p l a i n t

W e ' l l f o r w a r d y o u r i s s u e t o t h e c o m p a n y , g i v e y o u a t r a c k i n g n u m b e r , a n d k e e p y o u u p d a t e d o n t h e

s t a t u s o f y o u r c o m p l a i n t

.



### W H A T H A P P E N E D [ E D I T ]

D e s c r i b e w h a t h a p p e n e d s

o w e c a n u n d e r s t a n d t h e i s s u e . . . T h i s i s t h e w h a t h a p p e n e d f i e l d
C o n s e n t t o P u b l i s h ? C o n s e n t p r o v i d e d
T h i s i s a b o u t a ( n ) D o m e s t i c ( U S ) m o n e y t r a n s f e r W h i c h o f t h e s e b e s t d e s c r i b e s y o u r i s s u e ? M o n e y w a s n o t a v a i l a b l e w h e n p r o m i s e d



### D E S I R E D R E S O L U T I O N [ E D I T ]

W h a t d o y o u t h i n k w o u l d b e a f a i r r e s o l u t i o n t o y o u r i s s u e ? T h i s i s t h e d e s i r e d r e s o l u t i o n f i e l d



### C O N S U M E R I N F O R M A

T I O N [ E D I T ]

C o n t a c t i n f o r m a t i o n

M a i l i n g a d d r e s s F i r s t n a m e M i d d l e n a m e ( O p t i o n a l ) L a s t n a m e M a i l i n g a d d r e s s A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l ) C i t y D C Z i p C o d e U n i t e d S t a t e s E m a i l E m a i l @ c f p b

. g o v P h o n e P h o n e ( O p t i o n a l )

I a m s u b m i t t i n g o n b e h a l f o

f M y s e l f



### P R O D U C T I N F O R M A

T I O N [ E D I T ]

W h a t c o m p a n y w a s u s e d t o s e n d t h e m o n e y ? C o m p a n y n a m e C o m p a n y A d d r e s s C i t y Z i p C o d e ✓ W h a t h a p p e n e d ? ✓ D e s i r e d

r e s o l u t i o n ✓ M y

i n f o r m a t i o n ✓ P r o d u c t

i n f o r m a t i o n 5

. R e

v i e wA c c o u n t n u m b e r A c c o u n t n u m b e r ( O p t i o n a l )
W h e r e d i d t h e t r a n s a c t i o n t a k e p l a c e ? O n l i n e W e b s i t e o r n a m e o f m o b i l e a p p W e b s i t e o r n a m e o f m o b i l e a p p ( O p t i o n a l )



### S e n d e r I n f o r m a t i o n

F i r s t n a m e M i d d l e n a m e ( O p t i o n a l ) L a s t n a m e M a i l i n g a d d r e s s ( O p t i o n a l ) A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l ) C i t y ( O p t i o n a l ) D C Z i p c o d e U n i t e d S t a t e s
P h o n e ( O p t i o n a l )

E m a i l @ c f p b

. g o v H o w m u c h w a s t r a n s f e r r e d ? 0

. 0 0 U S D U n i t e d S t a t e s D o l l a r D a t e o f t r a n s f e r 3 / 1 / 2 0 1 5
W h a t i s t h e t r a n s f e r I D o r t r a n s a c t i o n n u m b e r ? I D o r n u m b e r F u n d s p r o m i s e d d a t e 3 / 3 1 / 2 0 1 5
A m o u n t o f e r r o r 0

. 0 0 U S D U n i t e d S t a t e s D o l l a r D a t e i s s u e o c c u r r e d 3 / 1 / 2 0 1 5



### P e r s o n r e c e i v i n g f u n d s

H o w w a s t h e t r a n s f e r r e c e i v e d ? D e p o s i t e d o r c r e d i t e d t o a n a c c o u n t C o m p a n y n a m e C o m p a n y a d d r e s s ( O p t i o n a l ) C i t y ( O p t i o n a l ) D C Z i p c o d e U n i t e d S t a t e s W e b s i t e o r n a m e o f m o b i l e a p p ( O p t i o n a l ) A c c o u n t n u m b e r ( O p t i o n a l )

F i r s t n a m e M i d d l e n a m e ( O p t i o n a l ) L a s t n a m e M a i l i n g a d d r e s s ( O p t i o n a l ) A p a r t m e n t , s u i t e , b u i l d i n g ( O p t i o n a l ) C i t y ( O p t i o n a l ) D C Z i p C o d e U n i t e d S t a t e s
P h o n e ( O p t i o n a l )

E m a i l @ c f p b

. g o v

T h e i n f o r m a t i o n g i v e n i s t r u e t o t h e b e s t o f m y k n o w l e d g e a n d b e l i e f

. I u n d e r s t a n d t h a t t h e C F P B

c a n n o t a c t a s m y l a w y e r , a c o u r t o f l a w , o r a f i n a n c i a l a d v i s o r

.

S u b m i t

O M B # 3 1 7 0

- 0 0 1 1 P r i v a c y a c t s t a t e m e n tA n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s G o v e r n m e n t 

# S u b m i t a d e b t c o l l e c t i o n c o m p l a i n t

F o r m t r o u b l e ? C h a t n o w . W h y d o w e n e e d t h i s ?

W h y d o w e n e e d t h i s ? 

### W h a t h a p p e n e d

W h a t t y p e o f d e b t i s t h i s ?

W h i c h o f t h e s e b e s t d e s c r i b e s y o u r i s s u e ?

W h a t p h o n e
n u m b e r a r e t h e y
c a l l i n g ? ( O p t i o n a l )

D e s c r i b e w h a t h a p p e n e d s o w e
c a n u n d e r s t a n d
t h e i s s u e

. . .



### D e s i r e d r e s o l u t i o n

W h a t d o y o u t h i n k

w o u l d b e a f a i r
r e s o l u t i o n t o y o u r i s s u e ? W H A T H A P P E N E D ?

C O M P A N Y I N F O R M A T I O N

I n c o m p l e t e

M Y I N F O R M A T I O N

I n c o m p l e t e

R E V I E W A N D S U B M I T

I n c o m p l e t e C r e d i t c a r d

M e d i c a l

A u t o

F e d e r a l s t u d e n t l o a n

N o n

- f e d e r a l s t u d e n t l o a n M o r t g a g e

P a y d a y l o a n

O t h e r ( i

. e

. p h o n e , h e a l t h c l u b

, e t c

. )

I d o n o t k n o w

C o m m u n i c a t i o n t a c t i c s

F r e q u e n t o r r e p e a t e d c a l l s

C a l l e d o u t s i d e o f 8 a m

- 9 p m

U s e d o b s c e n e , p r o f a n e o r o t h e r a b u s i v e l a n g u a g e

T h r e a t e n e d t o t a k e l e g a l a c t i o n

C a l l e d a f t e r s e n t w r i t t e n c e a s e o f c o m m u n i c a t i o n n o t i c e

T h i s i s t h e w h a t h a p p e n e d f i e l d

3 8 6 9 c h a r a c t e r s r e m a i n i n g

D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t

c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.
I w a n t t h e C F P B t o p u b l i s h t h i s d e s c r i p t i o n o n c o n s u m e r f i n a n c e

. g o v s o t h a t o t h e r s c a n l e a r n f r o m m y e x p e r i e n c e w i t h t h i s c o m p a n y

. I u n d e r s t a n d
t h a t t h e r e i s a s m a l l c h a n c e t h a t s o m e o n e m a y b e a b l e t o i d e n t i f y m e b a s e d

o n t h e i n f o r m a t i o n I ' v e i n c l u d e d

. L e a r n m o r e

T h i s i s t h e d e s i r e d r e s o l u t i o n f i e l d

3 8 6 4 c h a r a c t e r s r e m a i n i n g

D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t

c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.C O N T I N U E

H a v e q u e s t i o n s ? N e e d h e l p w i t h t h i s f o r m ? ( 8 5 5 ) 4 1 1

- 2 3 7 2 A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s g o v e r n m e n t P r i v a c y a c t s t a t e m e n t | O M B # 3 1 7 0

- 0 0 1 1A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s G o v e r n m e n t 

# S u b m i t a d e b t c o l l e c t i o n c o m p l a i n t

W h y d o w e n e e d t h i s ?

W h y d o w e n e e d t h i s ? 

### W h o ' s c o n t a c t i n g y o u a b o u t t h i s d e b t ?

D e b t c o l l e c t i o n
c o m p a n y n a m e :

A d d r e s s : ( O p t i o n a l )

C o u n t r y : ( O p t i o n a l ) Z i p c o d e : ( O p t i o n a l )

C i t y : ( O p t i o n a l ) S t a t e : ( O p t i o n a l )

P h o n e n u m b e r : ( O p t i o n a l )

R e p r e s e n t a t i v e
n a m e o r I D : ( O p t i o n a l )

A c c o u n t n u m b e r : ( O p t i o n a l )



### D o y o u k n o w w h e r e t h i s d e b t c a m e f r o m ?

D o y o u k n o w
w h e r e t h i s d e b t

c a m e f r o m ?

C o m p a n y n a m e :

A d d r e s s : ( O p t i o n a l )

A d d r e s s 2 : ( O p t i o n a l ) W H A T H A P P E N E D ? I d o n o t k n o w t h e d e b t c o l l e c t i o n
c o m p a n y n a m e C o m p a n y N a m e

C h o o s e

. . .

C h o o s e

. . .

A d d a n o t h e r n u m b e r

S a m e c o m p a n y A d i f

f e r e n t c o m p a n y I d o n ' t k n o w

I d o n o t k n o w t h e
c o m p a n y n a m e C o m p a n y N a m eW h y d o w e n e e d t h i s ?

C O N T I N U E C o u n t r y : ( O p t i o n a l ) Z i p : ( O p t i o n a l )

C i t y : ( O p t i o n a l ) S t a t e : ( O p t i o n a l )

P h o n e n u m b e r : ( O p t i o n a l )

R e p r e s e n t a t i v e
n a m e o r I D : ( O p t i o n a l )

A c c o u n t n u m b e r : ( O p t i o n a l )

S u b m i t a s e p a r a t e
c o m p l a i n t a g a i n s t t h i s c o m p a n y ?



### U p l o a d a n y s u p p o r t i n g d o c u m e n t s

A t t a c h d o c u m e n t s ( O p t i o n a l ) F o r m t r o u b l e ? C h a t n o w . C O M P A N Y I N F O R M A T I O N

M Y I N F O R M A T I O N

I n c o m p l e t e

R E V I E W A N D S U B M I T

I n c o m p l e t e C h o o s e

. . .

C h o o s e

. . .

A d d a n o t h e r n u m b e r

Y e s N o

S E L E C T F I L E

W e a c c e p t a l l f i l e f o r m a t s e x c e p t e x e c u t a b l e f i l e s (

. e x e )

H a v e q u e s t i o n s ? N e e d h e l p w i t h t h i s f o r m ? ( 8 5 5 ) 4 1 1

- 2 3 7 2 A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s g o v e r n m e n t P r i v a c y a c t s t a t e m e n t | O M B # 3 1 7 0

- 0 0 1 1A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s G o v e r n m e n t 

# S u b m i t a d e b t c o l l e c t i o n c o m p l a i n t

F o r m t r o u b l e ? C h a t n o w . W h y d o w e n e e d t h i s ?

W h y d o w e n e e d t h i s ? 

### P e r s o n a l i n f o r m a t i o n

S a l u t a t i o n ( O p t i o n a l )

F i r s t N a m e : M i d d l e : ( O p t i o n a l )

L a s t N a m e : S u f f i x : ( O p t i o n a l )

L a s t f o u r d i g i t s o f S o c i a l S e c u r i t y N u m b e r : ( O p t i o n a l )

A g e : ( O p t i o n a l )



### C o n t a c t i n f o r m a t i o n

A d d r e s s :

A d d r e s s 2 : ( O p t i o n a l )

C o u n t r y : Z i p c o d e :

C i t y : S t a t e :

P h o n e N u m b e r : ( O p t i o n a l )

E m a i l : W H A T H A P P E N E D ?

C O M P A N Y I N F O R M A T I O N

M Y I N F O R M A T I O N

I n c o m p l e t e

R E V I E W A N D S U B M I T

I n c o m p l e t e C h o o s e

. . .

C h o o s e

. . .

C o m p a n i e s m a t c h t h i s i n f o r m a t i o n t o t h e i r r e c o r d s t o r e s p o n d t o y o u r
c o m p l a i n t

. N o t p r o v i d i n g m a y d e l a y o r p r e v e n t t h e c o m p a n y f r o m r e s p o n d i n g t o y o u r c o m p l a i n t

.

U n i t e d S t a t e s

C h o o s e

. . .W h y d o w e n e e d t h i s ?

C O N T I N U E 

### M i l i t a r y a f f i l i a t i o n

T h e c o n s u m e r i s
n o w o r w a s : ( O p t i o n a l ) ( C h o o s e a l l t h a t a p p l y )

S a l u t a t i o n : ( O p t i o n a l )

F i r s t N a m e : M i d d l e ( O p t i o n a l )

L a s t N a m e : S u f f i x : ( O p t i o n a l )

A d d r e s s :

A d d r e s s 2 :

C o u n t r y : Z i p c o d e :

C i t y : S t a t e :

S t a t u s : B r a n c h :

R a n k : A

s e r v i c e m e m b e r

T h e d e p e n d e n t o r s p o u s e o f a
s e r v i c e m e m b e r

P l e a s e e n t e r t h e s e r v i c e m e m b e r i n f o r m a t i o n b e l o w

.

C h o o s e

. . .

C h o o s e

. . .

C h o o s e

. . .

C h o o s e

. . .

C h o o s e

. . . C h o o s e

. . .

C h o o s e

. . .H a v e q u e s t i o n s ? N e e d h e l p w i t h t h i s f o r m ? ( 8 5 5 ) 4 1 1

- 2 3 7 2 A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s g o v e r n m e n t P r i v a c y a c t s t a t e m e n t | O M B # 3 1 7 0

- 0 0 1 1A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s G o v e r n m e n t 

# S u b m i t a d e b t c o l l e c t i o n c o m p l a i n t

O n l y t h e h i g h l i g h t e d i n f o r m a t i o n b e l o w w i l l b e s e n t t o t h e s e c o m p a n i e s

.



### R e v i e w y o u r i n f o r m a t i o n
W H A T H A P P E N E D ? E d i t t h i s s e c t i o n

W h a t t y p e o f d e b t i s t h i s ?
C r e d i t c a r d

W h i c h o f t h e s e b e s t d e s c r i b e s y o u r i s s u e ?
C a l l e d o u t s i d e o f 8 a m
- 9 p m

D e s c r i b e w h a t h a p p e n e d s o w e c a n u n d e r s t a n d t h e i s s u e

. . .

T h i s i s t h e w h a t h a p p e n e d f i e l d

C o n s e n t t o P u b l i s h ?
C o n s e n t p r o v i d e d

W h a t d o y o u t h i n k w o u l d b e a f a i r r e s o l u t i o n t o y o u r i s s u e ?

T h i s i s t h e d e s i r e d r e s o l u t i o n f

i e l d

C O M P A N Y I N F O R M A

T I O N E d i t t h i s s e c t i o n

D e b t c o l l e c t i o n c o m p a n y C o m p a n y N a m e

D o y o u k n o w w h e r e t h i s d e b t c a m e f r o m ?

A d i f f e r e n t c o m p a n y

O r i g i n a l c r e d i t o r C o m p a n y N a m e

M Y I N F O R M A T I O N E d i t t h i s s e c t i o n

Y o u r n a m e
F i r s t N a m e L a s t N a m e T h e l a s t f o u r d i g i t s o f y o u r S S N
S S N

M a i l i n g a d d r e s s
A d d r e s s C i t y D C 2 0 0 0 0 U n i t e d S t a t e s C o n t a c t i n f o r m a t i o n

e m a i l @ c f p b

. g o v

Y o u r a g e i s

2 5 F o r m t r o u b l e ? C h a t n o w . W H A T H A P P E N E D ?

C O M P A N Y I N F O R M A T I O N

M Y I N F O R M A T I O N

R E V I E W A N D S U B M I T

I n c o m p l e t eT h e i n f o r m a t i o n g i v e n i s t r u e t o t h e b e s t o f m y k n o w l e d g e a n d b e l i e f

. I u n d e r s t a n d t h a t t h e C F P B c a n n o t a c t a s m y l a w y e r , a c o u r t

o f l a w , o r a f i n a n c i a l a d v i s o r

. S U B M I T

H a v e q u e s t i o n s ? N e e d h e l p w i t h t h i s f o r m ? ( 8 5 5 ) 4 1 1

- 2 3 7 2 A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s g o v e r n m e n t P r i v a c y a c t s t a t e m e n t | O M B # 3 1 7 0

- 0 0 1 1A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s G o v e r n m e n t


# S u b m i t a p a y d a y o r o t h e r c o n s u m e r l o a n c o m p l a i n t

F o r m t r o u b l e ? C h a t n o w . W h y d o w e n e e d t h i s ?

W h y d o w e n e e d t h i s ? 

### I f y o u r c o m p l a i n t c o n c e r n s l e n d e r c o l l e c t i o n p r a c t i c e s o n y o u r l o a n , y o u
s h o u l d s u b m i t a D e b t C o l l e c t i o n c o m p l a i n t

.



### W h a t h a p p e n e d

W h i c h t y p e o f l o a n i s y o u r
c o m p l a i n t a b o u t ?

W h i c h o f t h e s e b e s t d e s c r i b e s y o u r i s s u e ?

D e s c r i b e w h a t h a p p e n e d s o w e
c a n u n d e r s t a n d t h e i s s u e

. . .



### D e s i r e d r e s o l u t i o n

W h a t d o y o u t h i n k

w o u l d b e a f a i r
r e s o l u t i o n t o y o u r W H A T H A P P E N E D ?

I n c o m p l e t e

M Y I N F O R M A T I O N

I n c o m p l e t e

C O M P A N Y I N F O R M A T I O N

I n c o m p l e t e

R E V I E W A N D S U B M I T

I n c o m p l e t e I n s t a l l m e n t l o a n L o a n p a i d i n r e g u l a r f i x e d p a y m e n t s , R e n t

- t o

- O w n , a p p l i a n c e s , m e d i c a l

, e t c
P a w n l o a n L o a n s e c u r e d b y p e r s o n a l p r o p e r t y
T i t l e l o a n L o a n u s u a l l y s e c u r e d b y a v e h i c l e t i t l e
P a y d a y l o a n S h o r t

- t e r m l o a n o r c a s h a d v a n c e

C h a r g e d f e e s o r i n t e r e s t I d i d n ' t e x p e c t

C a n ' t s t o p l e n d e r f r o m c h a r g i n g m y b a n k a c c o u n t

R e c e i v e d a l o a n I d i d n ' t a p p l y f o r

A p p l i e d f o r a l o a n , b u t d i d n ' t r e c e i v e m o n e y

L e n d e r c h a r g e d m y b a n k a c c o u n t o n w r o n g d a y o r f o r w r o n g
a m o u n t

L e n d e r d i d n ' t c r e d i t p a y m e n t t o m y a c c o u n t

C a n ' t c o n t a c t l e n d e r

L e n d e r r e p o s s e s s e d o r s o l d t h e v e h i c l e

L e n d e r d a m a g e d o r d e s t r o y e d v e h i c l e

T h i s i s t h e w h a t h a p p e n e d f i e l d

3 8 6 9 c h a r a c t e r s r e m a i n i n g

D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t

c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.
I w a n t t h e C F P B t o p u b l i s h t h i s d e s c r i p t i o n o n c o n s u m e r f i n a n c e

. g o v s o t h a t o t h e r s c a n l e a r n f r o m m y e x p e r i e n c e w i t h t h i s c o m p a n y

. I u n d e r s t a n d
t h a t t h e r e i s a s m a l l c h a n c e t h a t s o m e o n e m a y b e a b l e t o i d e n t i f y m e b a s e d o n t h e i n f o r m a t i o n I ' v e i n c l u d e d

. L e a r n m o r e

T h i s i s t h e d e s i r e d r e s o l u t i o n f i e l dC O N T I N U E r e s o l u t i o n t o y o u r i s s u e ?

3 8 6 4 c h a r a c t e r s r e m a i n i n g

D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t

c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.

H a v e q u e s t i o n s ? N e e d h e l p w i t h t h i s f o r m ? ( 8 5 5 ) 4 1 1

- 2 3 7 2 A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s g o v e r n m e n t P r i v a c y a c t s t a t e m e n t | O M B # 3 1 7 0

- 0 0 1 1A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s G o v e r n m e n t


# S u b m i t a p a y d a y o r o t h e r c o n s u m e r l o a n c o m p l a i n t

F o r m t r o u b l e ? C h a t n o w . W h y d o w e n e e d t h i s ?

W h y d o w e n e e d t h i s ?

W h y d o w e n e e d t h i s ? 

### W h o i s t h e b o r r o w e r ?

W h o i s t h e b o r r o w e r o f t h e l o a n ?

W h a t i s y o u r
r e l a t i o n s h i p t o t h e b o r r o w e r ?



### B o r r o w e r i n f o r m a t i o n

S a l u t a t i o n ( O p t i o n a l )

F i r s t n a m e M i d d l e ( O p t i o n a l )

L a s t n a m e S u f f i x ( O p t i o n a l )

A d d r e s s

A d d r e s s 2 ( O p t i o n a l )

C o u n t r y Z i p c o d e

C i t y S t a t e

A g e ( O p t i o n a l )



### Y o u r i n f o r m a t i o n

S a l u t a t i o n ( O p t i o n a l )

F i r s t n a m e M i d d l e ( O p t i o n a l )

L a s t n a m e S u f f i x ( O p t i o n a l )

A d d r e s s W H A T H A P P E N E D ?

M Y I N F O R M A T I O N

I n c o m p l e t e

C O M P A N Y I N F O R M A T I O N

I n c o m p l e t e

R E V I E W A N D S U B M I T

I n c o m p l e t e I a m t h e b o r r o w e r
I a m s u b m i t t i n g o n b e h a l f o f t h e b o r r o w e r

H o u s i n g c o u n s e l o r

C h o o s e

. . .

F i r s t n a m e

L a s t n a m e C h o o s e

. . .

A d d r e s s

U n i t e d S t a t e s

C h o o s e

. . .

C h o o s e

. . .

C h o o s e

. . .I f y o u e n t e r y o u r e m a i l

a d d r e s s h e r e , t h e C F P B w i l l

s e n d y o u a l l f u r t h e r
c o m m u n i c a t i o n s b y e m a i l

.

W h y d o w e n e e d t h i s ?

C O N T I N U E A d d r e s s 2 ( O p t i o n a l )

C o u n t r y Z i p c o d e

C i t y S t a t e

P h o n e n u m b e r ( O p t i o n a l )

E m a i l



### M i l i t a r y a f f i l i a t i o n

T h e b o r r o w e r i s ( O p t i o n a l ) ( C h o o s e a l l t h a t a p p l y )

C u r r e n t s t a t u s B r a n c h

R a n k U n i t e d S t a t e s

C h o o s e

. . .

A s e r v i c e m e m b e r o r

v e t e r a n
T h e s p o u s e o r d e p e n d e n t o f a s e r v i c e m e m b e r o r

v e t e r a n

C h o o s e

. . . C h o o s e

. . .

C h o o s e

. . .

H a v e q u e s t i o n s ? N e e d h e l p w i t h t h i s f o r m ? ( 8 5 5 ) 4 1 1

- 2 3 7 2 A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s g o v e r n m e n t P r i v a c y a c t s t a t e m e n t | O M B # 3 1 7 0

- 0 0 1 1A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s G o v e r n m e n t


# S u b m i t a p a y d a y o r o t h e r c o n s u m e r l o a n c o m p l a i n t

F o r m t r o u b l e ? C h a t n o w . W h y d o w e n e e d t h i s ?

W h y d o w e n e e d t h i s ?

W h y d o w e n e e d t h i s ?

C O N T I N U E 

### L o a n d e t a i l s

W h e r e d i d y o u g e t t h e l o a n ? ( O p t i o n a l )

I n w h i c h s t a t e i s t h e s t o r e l o c a t e d ? ( O p t i o n a l )

L o a n n u m b e r ( O p t i o n a l )



### C o m p a n y d e t a i l s

C o m p a n y n a m e

A d d r e s s ( O p t i o n a l )

C o u n t r y ( O p t i o n a l ) Z i p c o d e ( O p t i o n a l )

C i t y ( O p t i o n a l ) S t a t e ( O p t i o n a l )



### U p l o a d a n y s u p p o r t i n g d o c u m e n t s

A t t a c h d o c u m e n t s ( O p t i o n a l ) W H A T H A P P E N E D ?

M Y I N F O R M A T I O N

C O M P A N Y I N F O R M A T I O N

R E V I E W A N D S U B M I T

I n c o m p l e t e ( e v e n i f y o u a p p l i e d o n l i n e ) I n p e r s o n / a t a s t o r e O n l i n e

T h i s i s i m p o r t a n t b e c a u s e

d i f f e r e n t s t a t e s h a v e d i f f e r e n t l e n d i n g l a w s

. C h o o s e

. . .

C o m p a n y N a m e

U n i t e d S t a t e s

C h o o s e

. . .

S E L E C T F I L E

W e a c c e p t a l l f i l e f o r m a t s e x c e p t e x e c u t a b l e f i l e s (

. e x e )

H a v e q u e s t i o n s ? N e e d h e l p w i t h t h i s f o r m ? ( 8 5 5 ) 4 1 1

- 2 3 7 2 A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s g o v e r n m e n t P r i v a c y a c t s t a t e m e n t | O M B # 3 1 7 0

- 0 0 1 1A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s G o v e r n m e n t


# S u b m i t a p a y d a y o r o t h e r c o n s u m e r l o a n c o m p l a i n t

F o r m t r o u b l e ? C h a t n o w . 

### P l e a s e r e v i e w y o u r i n f o r m a t i o n b e l o w b e f o r e s u b m i t t i n g

. Y o u c a n r e t u r n t o a n y s e c t i o n t o m a k e c h a n g e s b y c l i c k i n g ' E d i t t h i s
s e c t i o n '

.

W H A T H A P P E N E D 

### E d i t t h i s s e c t i o n

W h i c h t y p e o f l o a n i s y o u r c o m p l a i n t

a b o u t ?

W h i c h o f t h e s e b e s t d e s c r i b e s y o u r i s s u e ?

D e s c r i b e w h a t h a p p e n e d s o w e
c a n u n d e r s t a n d t h e i s s u e

. . .

C o n s e n t t o P u b l i s h ?

W h a t d o y o u t h i n k

w o u l d b e a f a i r
r e s o l u t i o n t o y o u r i s s u e ?

M Y I N F O R M A T I O N 

### E d i t t h i s s e c t i o n

Y o u r n a m e

A d d r e s s

E m a i l

P h o n e ( O p t i o n a l )

W h o i s t h e b o r r o w e r o f t h e l o a n ? W H A T H A P P E N E D ?

M Y I N F O R M A T I O N

C O M P A N Y I N F O R M A T I O N

R E V I E W A N D S U B M I T

I n c o m p l e t e 

### T i t l e l o a n

C a n ' t c o n t a c t l e n d e r

T h i s i s t h e w h a t h a p p e n e d f i e l d

C o n s e n t n o t p r o v i d e d

T h i s i s t h e d e s i r e d r e s o l u t i o n f

i e l d

F i r s t N a m e L a s t N a m e

A d d r e s s C i t y D C 2 0 0 0 0 U n i t e d S t a t e s

E m a i l @ c f p b

. g o v

I a m t h e b o r r o w e rT h e i n f o r m a t i o n g i v e n i s t r u e t o t h e b e s t o f m y k n o w l e d g e a n d b e l i e f

. I u n d e r s t a n d t h a t t h e C F P B c a n n o t a c t a s m y l a w y e r , a c o u r t

o f l a w , o r a f i n a n c i a l a d v i s o r

. S U B M I T l o a n ?

A g e ( O p t i o n a l )

C O M P A N Y I N F O R M A

T I O N 

### E d i t t h i s s e c t i o n

W h e r e d i d y o u g e t t h e l o a n ? ( O p t i o n a l )

L o a n c o m p a n y

L o a n n u m b e r ( O p t i o n a l )

S u p p o r t i n g d o c u m e n t s ( O p t i o n a l ) 

### I n p e r s o n / a t a s t o r e D i s t r i c t O f C o l u m b i a

C o m p a n y N a m e U n i t e d S t a t e s

H a v e q u e s t i o n s ? N e e d h e l p w i t h t h i s f o r m ? ( 8 5 5 ) 4 1 1

- 2 3 7 2 A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s g o v e r n m e n t P r i v a c y a c t s t a t e m e n t | O M B # 3 1 7 0

- 0 0 1 1A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s G o v e r n m e n t


# S u b m i t a p r e p a i d c a r d c o m p l a i n t

F o r m t r o u b l e ? C h a t n o w . W h y d o w e n e e d t h i s ?

W h y d o w e n e e d t h i s ?

C O N T I N U E 

### W h a t h a p p e n e d

W h i c h o f t h e s e b e s t d e s c r i b e s y o u r i s s u e ?

D e s c r i b e w h a t h a p p e n e d s o w e
c a n u n d e r s t a n d t h e i s s u e

. . .



### D e s i r e d r e s o l u t i o n

W h a t d o y o u t h i n k

w o u l d b e a f a i r
r e s o l u t i o n t o y o u r i s s u e ? W H A T H A P P E N E D ?

M Y I N F O R M A T I O N

I n c o m p l e t e

C O M P A N Y I N F O R M A T I O N

I n c o m p l e t e

R E V I E W A N D S U B M I T

I n c o m p l e t e M a n a g i n g , o p e n i n g , o r c l o s i n g y o u r a c c o u n t

F e e s

U n a u t h o r i z e d t r a n s a c t i o n s o r o t h e r t r a n s a c t i o n i s s u e s

A d v e r t i s i n g , m a r k e t i n g o r d i s c l o s u r e s

A d d i n g m o n e y

O v e r d r a f t , s a v i n g s o r r e w a r d s f e a t u r e s

F r a u d o r s c a m

T h i s i s t h e w h a t h a p p e n e d f i e l d

3 8 6 9 c h a r a c t e r s r e m a i n i n g

D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t

c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.
I w a n t t h e C F P B t o p u b l i s h t h i s d e s c r i p t i o n o n c o n s u m e r f i n a n c e

. g o v s o t h a t o t h e r s c a n l e a r n f r o m m y e x p e r i e n c e w i t h t h i s c o m p a n y

. I u n d e r s t a n d
t h a t t h e r e i s a s m a l l c h a n c e t h a t s o m e o n e m a y b e a b l e t o i d e n t i f y m e b a s e d o n t h e i n f o r m a t i o n I ' v e i n c l u d e d

. L e a r n m o r e

T h i s i s t h e d e s i r e d r e s o l u t i o n f i e l d

3 8 6 4 c h a r a c t e r s r e m a i n i n g

D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t

c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.H a v e q u e s t i o n s ? N e e d h e l p w i t h t h i s f o r m ? ( 8 5 5 ) 4 1 1

- 2 3 7 2 A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s g o v e r n m e n t P r i v a c y a c t s t a t e m e n t | O M B # 3 1 7 0

- 0 0 1 1A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s G o v e r n m e n t


# S u b m i t a p r e p a i d c a r d c o m p l a i n t

F o r m t r o u b l e ? C h a t n o w . W h y d o w e n e e d t h i s ?

W h y d o w e n e e d t h i s ?

I f y o u e n t e r y o u r e m a i l

a d d r e s s h e r e , t h e C F P B w i l l

s e n d y o u a l l f u r t h e r
c o m m u n i c a t i o n s b y e m a i l

.

W h y d o w e n e e d t h i s ? 

### W h o i s t h e c a r d h o l d e r ?

W h o i s t h e
c a r d h o l d e r ?



### Y o u r i n f o r m a t i o n

S a l u t a t i o n ( O p t i o n a l )

F i r s t n a m e M i d d l e ( O p t i o n a l )

L a s t n a m e S u f f i x ( O p t i o n a l )

A d d r e s s

A d d r e s s 2 ( O p t i o n a l )

C o u n t r y Z i p c o d e

C i t y S t a t e

E m a i l

P h o n e n u m b e r ( O p t i o n a l )

A g e ( O p t i o n a l )



### M i l i t a r y a f f i l i a t i o n

I a m ( O p t i o n a l ) ( C h o o s e a l l t h a t a p p l y ) W H A T H A P P E N E D ?

M Y I N F O R M A T I O N

I n c o m p l e t e

C O M P A N Y I N F O R M A T I O N

I n c o m p l e t e

R E V I E W A N D S U B M I T

I n c o m p l e t e I a m t h e
c a r d h o l d e r
I a m s u b m i t t i n g o n b e h a l f o f t h e
c a r d h o l d e r

C h o o s e

. . .

C h o o s e

. . .

U n i t e d S t a t e s

C h o o s e

. . .

A s e r v i c e m e m b e r o r

v e t e r a n
T h e s p o u s e o r d e p e n d e n t o f a s e r v i c e m e m b e r o r

v e t e r a nC O N T I N U E

H a v e q u e s t i o n s ? N e e d h e l p w i t h t h i s f o r m ? ( 8 5 5 ) 4 1 1

- 2 3 7 2 A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s g o v e r n m e n t P r i v a c y a c t s t a t e m e n t | O M B # 3 1 7 0

- 0 0 1 1A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s G o v e r n m e n t


# S u b m i t a p r e p a i d c a r d c o m p l a i n t

W h y d o w e n e e d t h i s ?

W h y d o w e n e e d t h i s ?

W h y d o w e n e e d t h i s ?

C O N T I N U E 

### C a r d d e t a i l s

W h i c h t y p e o f

c a r d i s y o u r
c o m p l a i n t a b o u t ?



### C o m p a n y d e t a i l s

C o m p a n y n a m e

A d d r e s s ( O p t i o n a l )

C o u n t r y ( O p t i o n a l ) Z i p c o d e ( O p t i o n a l )

C i t y ( O p t i o n a l ) S t a t e ( O p t i o n a l )

P h o n e n u m b e r ( O p t i o n a l )



### U p l o a d a n y s u p p o r t i n g d o c u m e n t s

A t t a c h d o c u m e n t s ( O p t i o n a l ) F o r m t r o u b l e ? C h a t n o w . W H A T H A P P E N E D ?

M Y I N F O R M A T I O N

C O M P A N Y I N F O R M A T I O N

R E V I E W A N D S U B M I T

I n c o m p l e t e G o v e r n m e n t b e n e f i t p a y m e n t c a r d U s e d f o r r e c e i v i n g S o c i a l S e c u r i t y , u n e m p l o y m e n t c o m p e n s a t i o n o r a t a x r e f u n d

E l e c t r o n i c B e n e f i t T r a n s f e r / E B T c a r d U s e d f o r r e c e i v i n g w e l f a r e p a y m e n t s l i k e W I C

, T A N F

, & S N A P

I D p r e p a i d c a r d P r e p a i d c a r d a t t a c h e d t o a s t u d e n t o r o t h e r I D

T r a n s i t c a r d A t r a n s i t c a r d u s e d f o r s h o p p i n g a n y w h e r e
G i f t o r m e r c h a n t c a r d G i f t , l o y a l t y o r p r o m o t i o n a l c a r d i s u e d b y a s t o r e
G e n e r a l p u r p o s e c a r d U s e d f o r s h o p p i n g a n y w h e r e
M o b i l e w a l l e t M o n e y h e l d i n a m o b i l e , o n l i n e o r v i r t u a l a c c o u n t

P a y r o l l c a r d U s e d f o r r e c e i v i n g y o u r p a y c h e c k f r o m y o u r e m p l o y e r
O t h e r s p e c i a l p u r p o s e c a r d U s e d f o r h e a l t h c a r e , i n s u r a n c e , r e b a t e s , p h o n e o r d i s a s t e r a s s i s t a n c e

C o m p a n y N a m e

U n i t e d S t a t e s

C h o o s e

. . .

S E L E C T F I L E

W e a c c e p t a l l f i l e f o r m a t s e x c e p t e x e c u t a b l e f i l e s (

. e x e )H a v e q u e s t i o n s ? N e e d h e l p w i t h t h i s f o r m ? ( 8 5 5 ) 4 1 1

- 2 3 7 2 A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s g o v e r n m e n t P r i v a c y a c t s t a t e m e n t | O M B # 3 1 7 0

- 0 0 1 1A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s G o v e r n m e n t


# S u b m i t a p r e p a i d c a r d c o m p l a i n t

F o r m t r o u b l e ? C h a t n o w . 

### P l e a s e r e v i e w y o u r i n f o r m a t i o n b e l o w b e f o r e s u b m i t t i n g

. Y o u c a n r e t u r n t o a n y s e c t i o n t o m a k e c h a n g e s b y c l i c k i n g ' E d i t t h i s
s e c t i o n '

.

W H A T H A P P E N E D 

### E d i t t h i s s e c t i o n

W h i c h o f t h e s e b e s t d e s c r i b e s y o u r i s s u e ?

D e s c r i b e w h a t h a p p e n e d s o w e
c a n u n d e r s t a n d t h e i s s u e

. . .

C o n s e n t t o P u b l i s h ?

W h a t d o y o u t h i n k

w o u l d b e a f a i r
r e s o l u t i o n t o y o u r i s s u e ?

M Y I N F O R M A T I O N 

### E d i t t h i s s e c t i o n

Y o u r n a m e

A d d r e s s

E m a i l

P h o n e ( O p t i o n a l )

W h o i s t h e
c a r d h o l d e r ?

A g e ( O p t i o n a l ) W H A T H A P P E N E D ?

M Y I N F O R M A T I O N

C O M P A N Y I N F O R M A T I O N

R E V I E W A N D S U B M I T

I n c o m p l e t e 

### F e e s

T h i s i s t h e w h a t h a p p e n e d f i e l d

C o n s e n t n o t p r o v i d e d

T h i s i s t h e d e s i r e d r e s o l u t i o n f

i e l d

F i r s t N a m e L a s t N a m e

A d d r e s s C i t y D C 2 0 0 0 0 U n i t e d S t a t e s

E m a i l @ c f p b

. g o v

I a m t h e c a r d h o l d e rT h e i n f o r m a t i o n g i v e n i s t r u e t o t h e b e s t o f m y k n o w l e d g e a n d b e l i e f

. I u n d e r s t a n d t h a t t h e C F P B c a n n o t a c t a s m y l a w y e r , a c o u r t

o f l a w , o r a f i n a n c i a l a d v i s o r

. S U B M I T C O M P A N Y I N F O R M A

T I O N 

### E d i t t h i s s e c t i o n

W h i c h t y p e o f c a r d i s y o u r c o m p l a i n t

a b o u t ?

P r e p a i d c a r d

c o m p a n y

S u p p o r t i n g d o c u m e n t s ( O p t i o n a l ) 

### G e n e r a l p u r p o s e c a r d

C o m p a n y N a m e U n i t e d S t a t e s

H a v e q u e s t i o n s ? N e e d h e l p w i t h t h i s f o r m ? ( 8 5 5 ) 4 1 1

- 2 3 7 2 A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s g o v e r n m e n t P r i v a c y a c t s t a t e m e n t | O M B # 3 1 7 0

- 0 0 1 1A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s G o v e r n m e n t


# S u b m i t a n o t h e r f i n a n c i a l s e r v i c e c o m p l a i n t

W h y d o w e n e e d t h i s ?

W h y d o w e n e e d t h i s ? 

### W h a t h a p p e n e d

W h i c h t y p e o f

s e r v i c e i s y o u r
c o m p l a i n t a b o u t ?

W h i c h o f t h e s e b e s t d e s c r i b e s y o u r i s s u e ?

D e s c r i b e w h a t h a p p e n e d s o w e
c a n u n d e r s t a n d t h e i s s u e

. . .



### D e s i r e d r e s o l u t i o n

W h a t d o y o u t h i n k

w o u l d b e a f a i r
r e s o l u t i o n t o y o u r i s s u e ? F o r m t r o u b l e ? C h a t n o w . W H A T H A P P E N E D ?

M Y I N F O R M A T I O N

I n c o m p l e t e

C O M P A N Y I N F O R M A T I O N

I n c o m p l e t e

R E V I E W A N D S U B M I T

I n c o m p l e t e C h e c k c a s h i n g A s t o r e t h a t c a s h e s a c h e c k f o r a f e e
C r e d i t r e p a i r S e r v i c e s f o r i m p r o v i n g y o u r c r e d i t r e p o r t

D e b t s e t t l e m e n t S e r v i c e s f o r r e d u c i n g y o u r d e b t b a l a n c e
F o r e i g n c u r r e n c y e x c h a n g e T r a n s a c t i o n s t h a t c o n v e r t m o n e y b e t w e e n c u r r e n c i e s
M o n e y o r d e r A p r e p a i d c h e c k f o r a s e t a m o u n t o f m o n e y
R e f u n d a n t i c i p a t i o n c h e c k A c h e c k p a i d t o y o u b y a b a n k o r c o m p a n y w i t h y o u r e x p e c t e d t a x r e f u n d

T r a v e l e r ’ s / C a s h i e r ’ s c h e c k s A c h e c k w i t h s e c u r e d f u n d s f r o m a b a n k o r o t h e r f i n a n c i a l i n s t i t u t i o n

A d v e r t i s i n g a n d m a r k e t i n g

C u s t o m e r s e r v i c e / C u s t o m e r r e l a t i o n s

D i s c l o s u r e s

E x c e s s i v e f e e s

U n e x p e c t e d / O t h e r f e e s

I n c o r r e c t e x c h a n g e r a t e

F r a u d o r s c a m

T h i s i s t h e w h a t h a p p e n e d f i e l d

3 8 6 9 c h a r a c t e r s r e m a i n i n g

D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t

c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.
I w a n t t h e C F P B t o p u b l i s h t h i s d e s c r i p t i o n o n c o n s u m e r f i n a n c e

. g o v s o t h a t o t h e r s c a n l e a r n f r o m m y e x p e r i e n c e w i t h t h i s c o m p a n y

. I u n d e r s t a n d
t h a t t h e r e i s a s m a l l c h a n c e t h a t s o m e o n e m a y b e a b l e t o i d e n t i f y m e b a s e d o n t h e i n f o r m a t i o n I ' v e i n c l u d e d

. L e a r n m o r e

T h i s i s t h e d e s i r e d r e s o l u t i o n f i e l dC O N T I N U E 3 8 6 4 c h a r a c t e r s r e m a i n i n g

D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l s e c u r i t y n u m b e r i n t h i s f i e l d

. W e w i l l c o l l e c t

c e r t a i n p e r s o n a l i n f o r m a t i o n a t a l a t e r s t e p

.

H a v e q u e s t i o n s ? N e e d h e l p w i t h t h i s f o r m ? ( 8 5 5 ) 4 1 1

- 2 3 7 2 A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s g o v e r n m e n t P r i v a c y a c t s t a t e m e n t | O M B # 3 1 7 0

- 0 0 1 1A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s G o v e r n m e n t


# S u b m i t a n o t h e r f i n a n c i a l s e r v i c e c o m p l a i n t

F o r m t r o u b l e ? C h a t n o w . W h y d o w e n e e d t h i s ?

W h y d o w e n e e d t h i s ?

I f y o u e n t e r y o u r e m a i l

a d d r e s s h e r e , t h e C F P B w i l l

s e n d y o u a l l f u r t h e r
c o m m u n i c a t i o n s b y e m a i l

.

W h y d o w e n e e d t h i s ? 

### W h o r e c e i v e d t h i s s e r v i c e

W h o r e c e i v e d t h i s
s e r v i c e ?



### Y o u r i n f o r m a t i o n

S a l u t a t i o n ( O p t i o n a l )

F i r s t n a m e M i d d l e ( O p t i o n a l )

L a s t n a m e S u f f i x ( O p t i o n a l )

A d d r e s s

A d d r e s s 2 ( O p t i o n a l )

C o u n t r y Z i p c o d e

C i t y S t a t e

E m a i l

P h o n e n u m b e r ( O p t i o n a l )

A g e ( O p t i o n a l )



### M i l i t a r y a f f i l i a t i o n

I a m ( O p t i o n a l ) ( C h o o s e a l l t h a t a p p l y ) W H A T H A P P E N E D ?

M Y I N F O R M A T I O N

I n c o m p l e t e

C O M P A N Y I N F O R M A T I O N

I n c o m p l e t e

R E V I E W A N D S U B M I T

I n c o m p l e t e I r e c e i v e d t h i s
s e r v i c e
I a m s u b m i t t i n g o n b e h a l f o f t h e p e r s o n w h o r e c e i v e d t h i s
s e r v i c e

C h o o s e

. . .

C h o o s e

. . .

U n i t e d S t a t e s

C h o o s e

. . .

A s e r v i c e m e m b e r o r

v e t e r a n
T h e s p o u s e o r d e p e n d e n t o f a s e r v i c e m e m b e r o r

v e t e r a nC O N T I N U E

H a v e q u e s t i o n s ? N e e d h e l p w i t h t h i s f o r m ? ( 8 5 5 ) 4 1 1

- 2 3 7 2 A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s g o v e r n m e n t P r i v a c y a c t s t a t e m e n t | O M B # 3 1 7 0

- 0 0 1 1A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s G o v e r n m e n t


# S u b m i t a n o t h e r f i n a n c i a l s e r v i c e c o m p l a i n t

F o r m t r o u b l e ? C h a t n o w . W h y d o w e n e e d t h i s ?

W h y d o w e n e e d t h i s ?

C O N T I N U E 

### C o m p a n y d e t a i l s

C o m p a n y n a m e

A d d r e s s ( O p t i o n a l )

C o u n t r y ( O p t i o n a l ) Z i p c o d e ( O p t i o n a l )

C i t y ( O p t i o n a l ) S t a t e ( O p t i o n a l )

P h o n e n u m b e r ( O p t i o n a l )



### U p l o a d a n y s u p p o r t i n g d o c u m e n t s

A t t a c h d o c u m e n t s ( O p t i o n a l ) W H A T H A P P E N E D ?

M Y I N F O R M A T I O N

C O M P A N Y I N F O R M A T I O N

R E V I E W A N D S U B M I T

I n c o m p l e t e C o m p a n y N a m e

U n i t e d S t a t e s

C h o o s e

. . .

S E L E C T F I L E

W e a c c e p t a l l f i l e f o r m a t s e x c e p t e x e c u t a b l e f i l e s (

. e x e )

H a v e q u e s t i o n s ? N e e d h e l p w i t h t h i s f o r m ? ( 8 5 5 ) 4 1 1

- 2 3 7 2 A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s g o v e r n m e n t P r i v a c y a c t s t a t e m e n t | O M B # 3 1 7 0

- 0 0 1 1A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s G o v e r n m e n t


# S u b m i t a n o t h e r f i n a n c i a l s e r v i c e c o m p l a i n t

F o r m t r o u b l e ? C h a t n o w . 

### P l e a s e r e v i e w y o u r i n f o r m a t i o n b e l o w b e f o r e s u b m i t t i n g

. Y o u c a n r e t u r n t o a n y s e c t i o n t o m a k e c h a n g e s b y c l i c k i n g ' E d i t t h i s
s e c t i o n '

.

W H A T H A P P E N E D 

### E d i t t h i s s e c t i o n

W h i c h t y p e o f

s e r v i c e i s y o u r
c o m p l a i n t a b o u t ?

W h i c h o f t h e s e b e s t d e s c r i b e s y o u r i s s u e ?

D e s c r i b e w h a t h a p p e n e d s o w e
c a n u n d e r s t a n d t h e i s s u e

. . .

C o n s e n t t o P u b l i s h ?

W h a t d o y o u t h i n k

w o u l d b e a f a i r
r e s o l u t i o n t o y o u r i s s u e ?

M Y I N F O R M A T I O N 

### E d i t t h i s s e c t i o n

Y o u r n a m e

A d d r e s s

E m a i l

P h o n e ( O p t i o n a l )

W h o r e c e i v e d t h e
s e r v i c e ? W H A T H A P P E N E D ?

M Y I N F O R M A T I O N

C O M P A N Y I N F O R M A T I O N

R E V I E W A N D S U B M I T

I n c o m p l e t e 

### F o r e i g n c u r r e n c y e x c h a n g e

D i s c l o s u r e s

T h i s i s t h e w h a t h a p p e n e d f i e l d

C o n s e n t n o t p r o v i d e d

T h i s i s t h e d e s i r e d r e s o l u t i o n f

i e l d

F i r s t N a m e L a s t N a m e

A d d r e s s C i t y D C 2 0 0 0 0 U n i t e d S t a t e s

E m a i l @ c f p b

. g o v

I r e c e i v e d t h e s e r

v i c eT h e i n f o r m a t i o n g i v e n i s t r u e t o t h e b e s t o f m y k n o w l e d g e a n d b e l i e f

. I u n d e r s t a n d t h a t t h e C F P B c a n n o t a c t a s m y l a w y e r , a c o u r t

o f l a w , o r a f i n a n c i a l a d v i s o r

. S U B M I T A g e ( O p t i o n a l )

C O M P A N Y I N F O R M A

T I O N 

### E d i t t h i s s e c t i o n

F i n a n c i a l s e r v i c e
c o m p a n y

S u p p o r t i n g d o c u m e n t s ( O p t i o n a l ) 

### C o m p a n y N a m e U n i t e d S t a t e s

H a v e q u e s t i o n s ? N e e d h e l p w i t h t h i s f o r m ? ( 8 5 5 ) 4 1 1

- 2 3 7 2 A n o f f i c i a l w e b s i t e o f t h e U n i t e d S t a t e s g o v e r n m e n t P r i v a c y a c t s t a t e m e n t | O M B # 3 1 7 0

- 0 0 1 1L o g I n

E m a i l

P a s s w o r d

F o r g o t y o u r p a s s w o r d ?

N o t r e g i s t e r e d y e t ? S e t y o u r p a s s w o r d L o g I nT h i s i s a C o n s u m e r F i n a n c i a l P r o t e c t i o n B u r e a u ( C F P B ) i n f o r m a t i o n s y s t e m

. T h e C F P B i s a n i n d e p e n d e n t a g e n c y o f t h e U n i t e d S t a t e s G o v e r n m e n t

. C F P B i n f o r m a t i o n s y s t e m s a r e p r o v i d e d f o r t h e p r o c e s s i n g o f o f

f i c i a l i n f o r m a t i o n o n l y

. U n a u t h o r i z e d o r i m p r o p e r u s e o f t h i s s y s t e m m a y r e s u l t i n

a d m i n i s t r a t i v e a c t i o n , a s w e l l a s c i v i l a n d c r i m i n a l p e n a l t i e s

. B e c a u s e t h i s i s a C F P B i n f o r m a t i o n s y s t e m , y o u h a v e n o

r e a s o n a b l e e x p e c t a t i o n o f p r i v a c y r e g a r d i n g a n y c o m m u n i c a t i o n

o r d a t a t r a n s i t i n g o r s t o r e d o n t h i s i n f o r m a t i o n s y s t e m

. A l l d a t a

c o n t a i n e d o n C F P B i n f o r m a t i o n s y s t e m s i s o w n e d b y C F P B a n d
y o u r u s e o f t h e C F P B i n f o r m a t i o n s y s t e m s e r v e s a s y o u r c o n s e n t
t o y o u r u s a g e b e i n g m o n i t o r e d

, i n t e r c e p t e d

, r e c o r d e d

, r e a d

, c o p i e d

, c a p t u r e d o r o t h e r w i s e a u d i t e d i n a n y m a n n e r , b y

a u t h o r i z e d p e r s o n n e l

, i n c l u d i n g b u t n o t l i m i t e d t o e m p l o y e e s , c o n t r a c t o r s , a n d / o r a g e n t s o f t h e U n i t e d S t a t e s G o v e r n m e n t

. U s e r n a m e

P a s s w o r d

F o r g o t y o u r p a s s w o r d ? L o g i n

L o g I nL o g I n



## T e l l y o u r s t o r y

T h i s i s n o t a c o m p l a i n t f o r m

. G

o h e r e f o r c o m p l a i n t s

T e l l u s y o u r s t o r y , g o o d o r b a d

, a b o u t y o u r e x p e r i e n c e w i t h c o n s u m e r f i n a n c i a l p r o d u c t s

. Y o u r s t o r y
w i l l h e l p i n f o r m h o w w e w o r k t o p r o t e c t c o n s u m e r s a n d c r e a t e a f a i r e r m a r k e t p l a c e

.
D e s c r i b e w h a t h a p p e n e d

. . . * D o n o t i n c l u d e s e n s i t i v e i n f o r m a t i o n l i k e y o u r n a m e , c o n t a c t i n f o r m a t i o n , a c c o u n t n u m b e r , o r s o c i a l

s e c u r i t y n u m b e r i n t h i s f i e l d

. Y o u c a n p r o v i d e y o u r c o n t a c t i n f o r m a t i o n b e l o w

. 

### T h i s i s w h a t h a p p e n e d

S u b m i t a n o n y m o u s l y

I s t h i s a b o u t s o m e t h i n g y o u s a w w h i l e w o r k i n g f o r a f i n a n c i a l c o m p a n y ? * M o r t g a g e , c r e d i t c a r d

, s t u d e n t l o a n , e t c

.

Y e s N o

T e l l y o u r s t o r y T a g y o u r i s s u e

E m a i l

Z I P c o d e

F i r s t n a m e

L a s t n a m e

P h o n e 

### T a g y o u r i s s u e

E m a i l

Z i p C o d e

F i r s t n a m e

L a s t n a m e

P h o n e

### ABOUT A FINANCIAL PRODUCT OR SERVICE 

# Submit a complaint

**The complaint process**

You submit a complaint about an issue you have with a company about a consumer financial product or service. You will receive email updates and can log in to track the status of your complaint. **Complaint submitted** 

**Review and route** 

**Company response** 

**Consumer review** 

**Review and investigate** 

**Analyze and report**  The company will review your complaint, communicate with you as needed, and report back about the steps taken or that will be taken on the issue you identify in your complaint.

We will let you know when the company responds. You can review that response and give us feedback.

Complaint data is shared with state and federal law enforcement agencies. Complaints tell us about business practices that may pose risks to consumers. If we need more information, we’ll reach out and let you know.

Complaints help with our work to supervise companies, enforce federal consumer financial laws, and write better rules and regulations. We also report to Congress about the complaints we receive and post some consumer complaint data. We'll forward your complaint to the company and work to get a response from them. If we find that another government agency would be better able to assist, we will forward your complaint to them and let you know. 

# How to submit

**Online (recommended)** consumerfinance.gov/complaint **Over the phone** (855) 411-CFPB (2372)
**By mail** Consumer Financial Protection Bureau PO Box 4503, Iowa City, IA 52244 **By fax** (855) 237-2392

# 1 **OF** 

# 7

**What happened?**

We want to understand your situation to help pinpoint what went wrong. Including facts and details like dates and where transactions happened can help.

**Describe what happened so we**  **can understand the issue...** 

Avoid including any of your personal contact information here. We will collect your personal information at a later step.



### What do you think **would be a fair resolution to your**  **issue?**

Avoid including any of your personal contact information here. We will collect your personal information at a later step. 

# Desired resolution

We want to understand what you think would be a fair resolution to the issue. We’ll forward this information to the company along with your description of what happened so that all parties involved can understand what you’re looking for. 1

2

# 2 **OF** 

# 7

**Estimate the total dollar value**  **of your loss based on what you know**  **right now.**

OPTIONAL 

### What is your **complaint about?**

CHOOSE ONE



### In a few words, **what is your issue with this product**  **or service?** BANK ACCOUNT OR SERVICE

CREDIT CARD

CREDIT REPORTING

MONEY TRANSFER MORTGAGE

PAYDAY LOAN

PREPAID CARD

STUDENT LOAN VEHICLE LOAN OR LEASE

OTHER CONSUMER LOAN

OTHER FINANCIAL SERVICE 3

4 

# Product or service type

MM DD YYYY 

### When did this **happen?**

OPTIONAL



### Have you done any **of these things to try to resolve this**  **issue?**

OPTIONAL CONTACTED COMPANY DIRECTLY CONTACTED ANOTHER GOVERNMENT AGENCY FILED LEGAL ACTION

CONTACTED CONSUMER FINANCIAL PROTECTION BUREAU HIRED AN ATTORNEY OTHER $



### 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. **5**

**6**

**7**

# 3 **OF** 

# 7

**Have you missed any mortgage**  **payments or are you in default on**  **your mortgage?**

OPTIONAL 

# Mortgage questions, if applicable

Filing a complaint will not automatically delay or stop a foreclosure. If you are not submitting a mortgage complaint, skip this page.

**Are you concerned about losing**  **your home to foreclosure?** 

OPTIONAL



### Is there a date **scheduled for the foreclosure sale of**  **your home?**

OPTIONAL



### Did you pay **a company to help you avoid**  **foreclosure?**

OPTIONAL 

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

OPTIONAL 

### 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.

If a foreclosure sale has been scheduled, you might have received a “Notice of Sale” or “Order Setting Sale.”

Please provide the exact date, if you can. This should be on the “Notice of Sale” or the “Order Setting Sale.”

Sometimes called “foreclosure rescue,” “foreclosure defense,” “foreclosure prevention,” or “loss mitigation assistance.” YES

YES

YES

YES NO

NO

NO

DON’T KNOW

NO **10a**

**11 10**  **9 8** 

MM DD YYYY

# 4 **OF** 

# 7

**Account holder’s information** 

**Account number**

**Contact information of**  **person submitting this complaint** 

If you are submitting on behalf of someone else, include your information here. We’ll use it to contact you about the status of this complaint. FIRST NAME FIRST NAME

LAST NAME LAST NAME

SUFFIX SUFFIX

EMAIL

EMAIL AGE PHONE NUMBER

PHONE NUMBER 

### I am submitting **on behalf of:** MYSELF **FILL OUT QUESTIONS 13, 13A & 14**

SOMEONE ELSE **FILL OUT QUESTIONS 13, 13A, 14 & 15** 12

13

15 14 STREET

STREET CITY

CITY COUNTRY

COUNTRY STATE

STATE ZIP CODE

ZIP CODE 

### Account **holder’s age**

OPTIONAL 

# Personal information

**13a**

# 5 **OF** 

# 7

**Attach any supporting**  **documents** Please attach copies of any documents related to your case. Seeing the full versions of documents like contracts, letters, monthly statements, and transaction receipts is the best way for us to really understand your case. Do not include original versions. 

### Company name

**Company address**

OPTIONAL



### Phone number

OPTIONAL



### Website

OPTIONAL 

# Information about the company

16

STREET

CITY COUNTRY STATE ZIP CODE **16a**

**16b**

**16c**

# 6 **OF** 

# 7

ACTIVE

RESERVE

NATIONAL GUARD

RETIRED

VETERAN



### Servicemember **personal information** 

OPTIONAL 

### The account holder **is now or was:**
OPTIONAL,
CHECK ALL THAT APPLY



### Service details
OPTIONAL,
CHOOSE ONE
IN EACH COLUMN 

### There are certain protections that apply to servicemembers and their spouses and dependents. If you have no affiliation with the military, skip this page.

A SERVICEMEMBER

THE SPOUSE / DEPENDENT OF A SERVICEMEMBER



### Current status **Branch Rank** 

ARMY

NAVY

MARINES

AIR FORCE

COAST GUARD

PUBLIC HEALTH SERVICE

NATIONAL OCEANIC & ATMOSPHERIC ADMIN E1 - E4

E5 - E7

E8 - E9

O1 - O3

O4 - O6

O7 - O10

W01 - CW5 **FILL OUT QUESTION 17A**

**FILL OUT QUESTIONS 17A & 17B**

FIRST NAME LAST NAME SUFFIX

STREET

CITY COUNTRY STATE ZIP CODE 

# Military affiliation, if applicable

**17**

**17a**

**17b**

# 7 **OF** 

# 7

**The information 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.**  

# Certify

The information you provide will permit the Consumer Financial Protection Bureau to respond to your complaint or inquiry about companies and services we supervise. Information 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 part 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 purposes; 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 collection 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 the requested information, the CFPB may not be able to act on your complaint.

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 estimate that it takes about 7 to 10 minutes to finish completing the form. Our OMB control number for this form is 3170-0011 and expires on 5/31/2015. Comments or suggestions? Email us at PRA@cfpb.gov. 

# Privacy Act Statement

**Notice of Consumer Information Collection**

### SOBRE PRODUCTOS O SERVICIOS FINANCIEROS 

# Formulario de queja

**Después de presentar una queja**

Usted presenta una queja sobre un problema que tenga con una empresa acerca de un producto o servicio financiero de consumo. Usted recibirá actualizaciones por correo electrónico y podrá entrar al sistema para darle seguimiento al estado de su queja. **Presentación de la queja** 

**Revisión y proceso** 

**Respuesta de la empresa** 

**Revisión del consumidor** 

**Revisión e investigación** 

**Análisis e informe**  La empresa revisará su queja, se comunicará con usted cuando sea necesario y le informará Acerca de las medidas que se tomaron o que se tomarán en respuesta a su queja. En estos momentos, nuestros informes están en inglés, pero nos puede llamar al (855) 411-2372 para recibir ayuda de una persona que habla español.

Le informaremos sobre la respuesta de la empresa cuando recibamos la misma. Usted podrá revisar la respuesta y darnos su opinión.

Los datos de las quejas se comparten con las autoridades estatales y federales. Las quejas nos informan sobre las prácticas comerciales que creen riesgos para los consumidores ocasionar riesgos a los consumidores. Si necesitamos más información, se lo haremos saber.

Las quejas ayudan con nuestro trabajo para supervisar a las empresas, hacer cumplir las leyes federales de protección al consumidor y redactar mejores normas y reglamentos. Asimismo, informamos al Congreso acerca de las quejas que recibimos y publicamos algunos datos de quejas de los consumidores. Enviaremos su queja a la empresa y trabajaremos para obtener una respuesta. Si consideramos que otra agencia del gobierno está en mejores condiciones de ayudar, le enviaremos su queja a la misma y se lo informaremos. 

# Cómo presentar una queja

**Por Internet (recomendado)** consumerfinance.gov/complaint **Por teléfono** (855) 411-CFPB (2372)

**Por correo** Oficina para la Protección Financiera del Consumidor PO Box 4503, Iowa City, IA 52244 **Por fax** (855) 237-2392

# 1 **DE** 

# 7

**¿Qué pasó?**

Queremos entender su situación para poder identificar con precisión el problema que dio lugar a su queja. Si usted nos proporciona los detalles de lo ocurrido —como las fechas y lugares de las transacciones; entonces podremos entender mejor su queja.

**Describa lo que pasó, para que**  **podamos entender el problema.** 

No incluya aquí ninguna de su información de contacto personal. Le pediremos esta información en un paso posterior.



### ¿Qué piensa usted **que sería una resolución justa**  **del problema?**

No incluya aquí ninguna de su información de contacto personal. Le pediremos esta información en un paso posterior. 

# ¿Cómo quiere que se resuelva su queja?

Queremos saber que piensa usted que sería una resolución justa del problema. Le enviaremos esta información a la empresa, junto con su descripción de lo ocurrido, para que entiendan lo que usted busca. 1

2

# 2 **DE** 

# 7

**Basándose en lo que usted sabe**  **en este momento, calcule el monto**  **en dólares de lo perdido.** 

OPCIONAL 

### ¿De qué se trata **esta queja?**

ESCOJA UNO



### Cuéntenos en pocas **palabras cuál fue el problema con este**  **producto o servicio.** CUENTA O SERVICIO BANCARIO

TARJETA DE CRÉDITO

INFORME DE CRÉDITO

TRANSFERENCIA DE DINERO HIPOTECA

PRÉSTAMO DE AVANCE DE PAGO

TARJETA PREPAGADA

PRÉSTAMO ESTUDIANTIL PRÉSTAMO O ARRENDAMIENTO
VEHICULAR

OTRO PRÉSTAMO DE CONSUMO

OTRO SERVICIO FINANCIERO 3

4 

# Tipo de producto o servicio

MM DD AAAA 

### ¿Cuándo ocurrió **esto?**

OPCIONAL



### ¿Ha tratado **de resolver el problema**  **tomando alguna de las siguientes**  **medidas?**

OPCIONAL COMUNICARSE DIRECTAMENTE CON LA EMPRESA COMUNICARSE CON OTRA AGENCIA DEL GOBIERNO INICIAR ACCIONES LEGALES

COMUNICARSE CON LA OFICINA PARA LA PROTECCIÓN FINANCIERA DEL CONSUMIDOR CONTRATAR UN ABOGADO OTRO $



### Incluya detalles como, por ejemplo, los nombres e información de contacto de los organismos gubernamentales con los que se comunicó, las fechas en que se comunicó con ellos, los números de caso, el estado de tramitación de los casos, la información de contacto del abogado (si corresponde), etc. **5**

**6**

**7**

# 3 **DE** 

# 7

**¿Se ha atrasado con los pagos**  **de su préstamo hipotecario o está**  **en incumplimiento de pago del mismo?** 

OPCIONAL 

# Preguntas sobre préstamos hipotecarios (si corresponde)

La presentación de una queja no demorará ni detendrá, de forma automática, la ejecución hipotecaria. Si la queja que usted presenta no tiene que ver con un préstamo hipotecario, omita esta página.

**¿Le preocupa la posibilidad**  **de perder su propiedad debido**  **a la ejecución hipotecaria?** 

OPCIONAL



### ¿Se ha fijado una **fecha para la venta de su vivienda**  **por ejecución hipotecaria?** 

OPCIONAL



### ¿Le pagó dinero a **una empresa para que le ayudara a**  **evitar la ejecución hipotecaria?** 

OPCIONAL 

### De ser asi, ¿cuál **es la fecha programada para**  **la venta de su vivienda?** 

OPCIONAL 

### También debe marcar “Sí” si la compañía hipotecaria considera que usted está en incumplimiento de pago o que se ha atrasado con los pagos, incluso si usted cree que la compañía está equivocada.

Si ya se ha fijado la fecha para la venta de su vivienda por ejecución hipotecaria, puede que usted haya recibido una “Notificación de remate” u “Orden judicial de remate”.

Proporcione la fecha exacta, si puede. La fecha debe aparecer en la “Notificación de remate” u “Orden judicial de remate”.

A este servicio se le denomina a veces “rescate (o defensa o prevención) de la ejecución hipotecaria” o “mitigación (o control) de pérdidas”. SÍ

SÍ

SÍ

SÍ NO

NO

NO

NO SÉ

NO **10a**

**11 10**  **9 8** 

MM DD AAAA

# 4 **DE** 

# 7

**Datos del titular de la cuenta** 

**Número de cuenta**

**Información de contacto de quien**  **presenta la queja**

Si usted presenta la queja en representa

ción de otra persona, incluya aquí su propia información para que podamos informarle sobre el estado de tra

mitación de la queja. NOMBRE NOMBRE

APELLIDO(S) APELLIDO(S)

SUFIJO SUFIJO

CORREO ELECTRÓNICO

CORREO ELECTRÓNICO EDAD TELÉFONO

TELÉFONO 

### Presento la queja **en representación:** MÍA **CONTESTE LA PREGUNTA 13, 13A Y 14**

DE OTRA PERSONA **CONTESTE LAS PREGUNTAS 13, 13A, 14 Y 15** 12

13

15 14 CALLE Y NÚMERO

CALLE Y NÚMERO CIUDAD

CIUDAD PAÍS

PAÍS ESTADO

ESTADO CÓDIGO POSTAL

CÓDIGO POSTAL 

### Edad del titular **de la cuenta**

OPCIONAL 

# Datos personales

**13a**

# 5 **DE** 

# 7

**Adjuntar documentos**  **probatorios**

OPCIONAL 

### Adjunte copias de cualquier documento que acredite la queja. La mejor manera en que podamos entender su queja es si tenemos la versión completa de documentos como, por ejemplo, contratos, cartas, estados de cuenta mensuales y comprobantes de transacciones. No incluya el original de los documentos. 

### Nombre de la **empresa**

**Dirección de la empresa** 
OPCIONAL



### Teléfono

OPCIONAL



### Sitio web

OPCIONAL 

# Datos de la empresa

16

CALLE Y NÚMERO

CIUDAD PAÍS ESTADO CÓDIGO POSTAL **16a**

**16b**

**16c**

# 6 **DE** 

# 7

EN ACTIVIDAD

DE RESERVA

GUARDIA NACIONAL

EN RETIRO

VETERANO (EX COMBATIENTE)



### Datos personales **del integrante de las fuerzas**  **armadas**

OPCIONAL 

### El titular de la **cuenta es o era:**
OPCIONAL (INDIQUE TODOS LOS QUE CORRESPONDAN)



### Historial de **servicio militar**

OPCIONAL (ESCOJA UNA OPCIÓN EN CADA COLUMNA) 

### Hay algunas protecciones a las que se pueden acoger los militares y sus cónyuges y dependientes. Si usted no tiene ninguna afiliación militar ni es cónyuge o dependiente de un militar, omita esta página.

INTEGRANTE DE LAS FUERZAS ARMADAS (FF. AA.)

CÓNYUGE / DEPENDIENTE DE UN INTEGRANTE DE LAS FF. AA.



### Estado actual **Rama Rango** 

EJÉRCITO

MARINA
INFANTERÍA DE MARINA
FUERZA AÉREA

SERVICIO DE GUARDACOSTAS
SERVICIO DE SALUD PÚBLICA
ADMINISTRACIÓN NACIONAL DE OCÉANOS Y ATMÓSFERA E1 - E4

E5 - E7

E8 - E9

O1 - O3

O4 - O6

O7 - O10

W01 - CW5 **CONTESTE LA PREGUNTA 17A**

**CONTESTE LAS PREGUNTAS 17A Y 17B**

NOMBRE APELLIDO(S) SUFIJO

CALLE Y NÚMERO

CIUDAD PAÍS ESTADO CÓDIGO POSTAL 

# Historial militar (si corresponde)

**17**

**17a**

**17b**

# 7 **DE** 

# 7

**La información proporcionada es verdadera a mi leal saber y entender. Entiendo que la CFPB no puede actuar como mi abogado, un tribunal o un asesor financiero.**  

# Certificación

La información que usted proporcione permitirá a la Oficina para la Protección Financiera del Consumidor (CFPB) atender su queja o consulta sobre las empresas y los servicios que supervisamos. La información sobre su queja o consulta (incluidos datos confidenciales) se puede poner a disposición de cualquiera de las siguen

tes partes:



# ▪ la empresa que es objeto de su queja;


# ▪ terceras partes, según sea necesario con el fin de ob

tener la información necesaria para atender la queja;


# ▪ tribunales, partes litigantes, abogados, entidades jurídicas o cortes administrativas, en el curso de un proceso judicial o administrativo, o el Departamento de Justicia;


# ▪ otros organismos o autoridades reguladoras, ya sean federales o estatales, para los fines establecidos por la ley o para los fines de cumplimiento de la ley, o


# ▪ contratantes, agentes y otras partes autorizadas por la CFPB para recibir esta información. Por medio de una base de datos de quejas, también podemos poner a disposición del público su queja o consulta (salvo los datos confidenciales).
El presente instrumento de recolección de datos está autorizado por la Sección 5493 del Título 12 del Código de los Estados Unidos (12 U.S.C. §5493).
No es obligatorio presentar una queja o proporcionar datos confidenciales (incluyendo su número de Seguro Social). Además, puede retirar su queja en cualquier mo

mento. Sin embargo, si usted no incluye la información solicitada, es posible que la CFPB no pueda tomar acción en relación a su queja.

Número de control emitido por la Oficina de Administración y Presupuesto (OMB): 3170-0011
Utilizamos el presente formulario para recibir las quejas. Si usted no desea presentar una queja, no está obligado a llenar este formulario. Calculamos que se necesitan entre 7 y 10 minutos para llenar el formulario. El número de control emitido por la OMB para el formulario es 3170-0011 y tiene vigencia hasta el 31 de mayo de 2015. ¿Tiene usted algún comentario o sugerencia? Envíenos un mensaje a PRA@cfpb.gov. 

# Aviso sobre la Ley de Privacidad

**Aviso sobre la recolección de información del consumidor**

# 1 **OF** 

# 8

Debt was discharged in bankruptcy
Debt resulted from identity theft Debt was paid
Debt is not mine

Threatened to arrest me or take me to jail if I do not pay
Threatened to sue me on debt that is too old to be sued on Sued me without properly notifying me of lawsuit
Sued me where I did not live or did not sign for the debt Collected or attempted to collect exempt funds (i.e. unemployment, child support, etc.) Seized or attempted to seize property 

### Which of these **best describes your issue?** 

ENTER THE NUMBER OF
THE OPTION THAT BEST
DESCRIBES YOUR ISSUE 

### Communication tactics

**Improper contact or sharing of information**  **Continued attempts to collect a debt I do not owe** 

**False statements or representation**  **Disclosure or verification of debt** 

**Taking or threatening to take an illegal action**  Frequent or repeated calls
Called outside of 8am9pm Used obscene, profane or other abusive language Threatened to take legal action
Called after sent written cease of communication notice

Contacted me after I asked not to Contacted my employer after I asked not to
Contacted me instead of my attorney Talked to a third party about my debt Attempted to collect wrong amount Impersonated attorney, law enforcement or government official Indicated committing crime by not paying debt
Indicated should not respond to lawsuit Did not receive notice of right to dispute Not enough information to verify debt (i.e. amount of debt & name of creditor)
Did not disclose communication was an attempt to collect a debt **3A**

**4A 6A** 

**6D 1A** 
**2A**

**5A 3B** 

**4B 6B** 

**6E 1B** 
**2B**

**5B 3C** 

**4C 6C** 

**6F 4D**  **1C**
**2C**

**5C 1D**  **2D**

**5D 1E**  2 CREDIT CARD

MORTGAGE

AUTO MEDICAL

FEDERAL STUDENT LOAN

NON-FEDERAL STUDENT LOAN OTHER (I.E., PHONE, HEALTH CLUB, ETC.)

I DON’T KNOW 

### What type of debt **is this?**

CHOOSE ONE 

# What is this complaint about?

1

OPTION NUMBER



### If someone is **contacting you by phone, what**  **number are they calling?** 

OPTIONAL **3** PHONE NUMBER

# 2 **OF** 

# 8

We want to know what happened. Providing facts and details like dates and where transactions occurred helps us understand your complaint. For example, did someone call you? Did you visit a company in person?

**Describe what happened so we**  **can understand the issue** 

Do not include sensitive information like your name, contact information, account number, or Social Security Number in this field. We will collect certain personal information at a later step.



### What do you think **would be a fair resolution to your**  **issue?**

Do not include sensitive information like your name, contact information, account number, or Social Security Number in this field. 

# What happened?

**Desired Resolution**

We want to understand what you think would be a fair resolution to this issue. We’ll forward this information to the company along with your description of what happened so that all parties know what you are looking for. 4

5

# 3 **OF** 

# 8

We want to know as much as you can tell us about the company collecting the debt. Even if you don’t know the com

pany’s name, provide any phone numbers for the company, a representative name, or an account number and we’ll try to match things up on our end.

**Attach any supporting**  **documents** Here we’re asking for copies of any documents about your complaint. Documents like contracts, letters, monthly statements, and transaction receipts can help us better understand your complaint. 

### Debt collection **company name** 

# Who’s contacting you about this debt?

**Company contact information** 

OPTIONAL
Even if you don’t know the company’s name, please try your best to provide any phone numbers for the company, a representative name, or an account number and we’ll try to match things up on our end. REPRESENTATIVE NAME OR ID

ACCOUNT NUMBER PHONE NUMBER STREET

CITY COUNTRY STATE ZIP CODE 6

**6a** I DON’T KNOW THE DEBT COLLECTION COMPANY NAME

# 4 **OF** 

# 8

**Company name Do you know**  **where this debt came from?** 
OPTIONAL,
CHOOSE ONE 

# Do you know where this debt came from?

We want to know if the company contacting you was hired by a different company to collect on a debt. If the debt is with a different company, we’ll give you the option to submit two complaints about your issue: one complaint about the debt collector and a second complaint about the company that owns the debt.
If you don’t know where the debt came from, choose “I don’t know.”

**Company contact information** 

Even if you don’t know the company’s name, please try your best to provide any phone numbers for the company, a representative name, or an account number and we’ll try to match things up on our end.



### Submit a separate **complaint against this company?**  ACCOUNT NUMBER



### By selecting yes, we will create a separate complaint against this company. This will be in addition to your complaint against the debt collection company. SAME COMPANY

YES DIFFERENT COMPANY

NO I DON’T KNOW FILL OUT QUESTIONS 8 & 9

CONTINUE TO QUESTION 10 CONTINUE TO QUESTION 10

**8a**

**9 8**  **7**

REPRESENTATIVE NAME OR ID PHONE NUMBER STREET

CITY COUNTRY STATE ZIP CODE I DON’T KNOW THE COMPANY NAME

# 5 **OF** 

# 8

The company needs your full name and the last four digits of your Social Security Number to match your complaint to their records and respond to your complaint.

**Consumer’s identification**  **information**

We’ll use this information to contact you about the status of your complaint.



### Contact **information of person submitting**  **complaint** FIRST NAME FIRST NAME

LAST NAME LAST NAME

LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER

SUFFIX SUFFIX

AGE Companies match this information to their records to respond to your complaint. Not providing may delay or prevent the company from responding to your complaint. EMAIL PHONE NUMBER

PHONE NUMBER 

### Are you filing on **behalf of someone else?**  YES, I AM FILING ON BEHALF OF SOMEONE ELSE FILL OUT QUESTIONS 11 & 12

NO, I AM FILING ON BEHALF OF MYSELF FILL OUT QUESTION 11 10

11

**12** STREET

STREET CITY

CITY COUNTRY

COUNTRY STATE

STATE ZIP CODE

ZIP CODE 

### Additional **identification**

OPTIONAL **11a** 

# Personal information

# 6 **OF** 

# 8

ACTIVE

RESERVE

NATIONAL GUARD

RETIRED

VETERAN



### Servicemember **personal information**  **The consumer is**

**now or was:** OPTIONAL,
CHECK ALL THAT APPLY



### Service details

CHOOSE ONE
IN EACH COLUMN 

### There are certain protections that apply to servicemembers and their spouses and dependents.

A SERVICEMEMBER

THE SPOUSE / DEPENDENT OF A SERVICEMEMBER



### Current status **Branch Rank** 

ARMY

NAVY

MARINES

AIR FORCE

COAST GUARD

PUBLIC HEALTH SERVICE

NATIONAL OCEANIC & ATMOSPHERIC ADMIN E1 - E4

E5 - E7

E8 - E9

O1 - O3

O4 - O6

O7 - O10

W01 - CW5 FILL OUT QUESTION 13A

FILL OUT QUESTIONS 13A & 13B

FIRST NAME LAST NAME SUFFIX

STREET

CITY COUNTRY STATE ZIP CODE 

# Military affiliation

**13**

**13a**

**13b**

# 7 **OF** 

# 8

**The information 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.** 

SIGNATURE DATE 

# Authorization

**Ways to submit this form**

**Other ways to submit your complaint**

**Online** consumerfinance.gov/complaint **Over the phone** (855) 411-2372 **By mail** Consumer Financial Protection Bureau PO Box 4503, Iowa City, IA 52244 **By fax** (855) 237-2392

# 8 **OF** 

# 8

The information you provide will permit the Consumer Financial Protection Bureau to respond to your complaint or inquiry about companies and services we supervise. Information 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 part in litigation, a magistrate, an adju

dicative 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 purposes; 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 collection of information is authorized by 12 U.S.C. § 5493.
You are not required to file a complaint or share any iden

tifying information, including your social security number, and you may withdraw your complaint at any time. How

ever, if you do not include the requested information, the CFPB may not be able to act on your complaint.

OMB Control Number 3170-0011
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 estimate that it takes about 7 to 10 minutes to finish completing the form. Our OMB control number for this form is 3170-0011 and expires on 5/31/2015. Comments or suggestions? Email us at PRA@cfpb.gov. 

# Privacy Act Statement

**Notice of Consumer Information Collection**

# 1 **DE** 

# 8

La deuda fue eliminada por quiebra
La deuda es el resultado del robo de identidad
La deuda fue saldada
La deuda no es mía

Amenazaron con arrestarme o llevarme a la cárcel si no pago la deuda

Amenazaron con demandarme por una deuda que está exenta por su antigüedad
Me demandaron sin darme la debida notificación Me demandaron en un lugar donde no residí o donde no contraje la deuda Embargaron o intentaron embargar ingresos que están exentos para efectos del cobro de la deuda (seguro de desempleo, pensión para los hijos, etc.) Tomaron posesión de bienes o intentaron hacerlo 

### ¿Cuál de las **siguientes opciones mejor**  **describe su problema?**  ESCRIBA EL NÚMERO DE LA OPCIÓN QUE MEJOR
DESCRIBA SU PROBLEMA 

### Tácticas de comunicación

**Comunicación inoportuna o cesión**  **indebida de datos Intentos repetidos de**  **cobrar deudas que no me corresponden** 

**Falsa declaración o representación**  **Omisión de información obligatoria o de la**  **verificación de la deuda**

**Amenazas o iniciación de medidas ilegales**  Llaman frecuentemente o repetidamente
Llaman antes de las 8am o después de las 9pm Usan lenguaje soez, ofensivo o insultante

Amenazan con acción legal Siguen llamando tras recibir por escrito que suspendan comunicaciones

No hicieron caso a mi petición de que no se comunicaran conmigo
No hicieron caso a mi petición de que no se comunicaran con mi empleador Se comunicaron conmigo y no con mi abogado
Hablaron con terceros sobre mi deuda Intentaron cobrar un monto indebido Se hicieron pasar por abogados o por funcionarios del orden público o del Gobierno Indicaron que violé la ley al no pagar la deuda Indicaron que no debo responder a la demanda No me informaron sobre mi derecho a impugnar la validez de la deuda No hay información suficiente para verificar la validez de la deuda (el monto y el acreedor) No me informaron que era un intento de cobrar una deuda **3A**

**4A 6A** 

**6D 1A** 

**2A**

**5A 3B** 

**4B 6B** 

**6E 1B** 

**2B**

**5B 3C** 

**4C 6C** 

**6F 4D**  **1C**

**2C**

**5C 1D** 
**2D**

**5D 1E**  2 TARJETA DE CRÉDITO
PRÉSTAMO HIPOTECARIO
AUTOMÓVIL CUENTAS MÉDICAS
PRÉSTAMO ESTUDIANTIL FEDERAL
PRÉSTAMO ESTUDIANTIL PRIVADO OTRO (TELÉFONO, GIMNASIO, ETC.)
NO SÉ 

### ¿Qué tipo de **deuda es?**

ESCOJA UNO 

# ¿De qué se trata esta queja?

1

NÚMERO DE OPCIÓN



### Si alguien se está **comunicando con usted por teléfono,**  **¿a qué número está llamando?** 

OPCIONAL **3** TELÉFONO

# 2 **DE** 

# 8

Queremos saber lo que sucedió. Si usted nos proporciona los detalles de lo ocurrido —como las fechas y lugares de las transacciones—entonces podremos entender mejor su queja. Por ejemplo: ¿Alguien le llamó por teléfono? ¿Usted visitó la empresa en persona?

**Describa lo que pasó, para que**  **podamos entender el problema.** 

No incluya aquí sus datos confidenciales, como su nombre y apellido, información de contacto, número de cuenta o número de Seguro Social. Le pediremos algunos de estos datos en un paso posterior.



### ¿Qué piensa usted **que sería una resolución justa del**  **problema?**

No incluya aquí sus datos confidenciales, como su nombre y apellido, información de contacto, número de cuenta o número de Seguro Social. 

# ¿Qué pasó?

**¿Cómo quiere que se resuelva su queja?**

Queremos saber que piensa usted que sería una resolución justa del problema. Le enviaremos esta información a la empresa, junto con su descripción de lo ocurrido, para que entiendan lo que usted busca. 4

5

# 3 **DE** 

# 8

Queremos saber tanto como usted nos pueda decir sobre la empresa que intenta cobrar la deuda. Aunque no sepa el nombre de la empresa, trate de proporcionar algún número de teléfono para la misma, el nombre de alguno de sus representantes o un número de cuenta. Por nuestra parte, haremos todo lo posible para localizar la empresa.

**Adjuntar documentos**  **probatorios**

OPCIONAL 

### Adjunte copias de cualquier documento que acredite la queja. La mejor manera en que podamos entender su queja es si tenemos la versión completa de documentos como, por ejemplo, contratos, cartas, estados de cuenta mensuales y comprobantes de transacciones. No incluya el original de los documentos. 

### Nombre de la **empresa de cobro de deudas**  

# ¿Quién se ha comunicado con usted respecto a esta deuda?

**Información de contacto de la**  **empresa de cobro de deudas** 

OPCIONAL Aunque no sepa el nombre de la empresa, trate de proporcionar algún número de teléfono para la misma, el nombre de alguno de sus representantes o un número de cuenta. Por nuestra parte, haremos todo lo posible para localizar la empresa. NOMBRE O IDENTIFICACIÓN DEL REPRESENTANTE

NÚMERO DE CUENTA TELÉFONO CALLE Y NÚMERO

CIUDAD PAÍS ESTADO CÓDIGO POSTAL 6

**6a** NO SÉ EL NOMBRE DE LA EMPRESA

# 4 **DE** 

# 8

**Nombre de la empresa acreedora**  **¿Sabe quien es el acreedor de esta**  **deuda?**

OPCIONAL 

# ¿Quien es el acreedor de esta deuda?

Queremos saber si la empresa que se puso en contacto con usted fue contratada por otra empresa para cobrar la deuda. Si esta otra empresa es el acreedor de la deuda, le daremos a usted la oportunidad de presentar dos quejas: una contra la empresa de cobro de deudas y otra contra la empresa acreedora.
Si usted no sabe quien es el acreedor de la deuda, elija “No sé”.

**Información de contacto de la**  **empresa acreedora**

Aunque no sepa el nombre de la empresa, trate de proporcionar algún número de teléfono para la misma, el nombre de alguno de sus representantes o un número de cuenta. Por nuestra parte, haremos todo lo posible para localizar la empresa.



### ¿Desea presentar **por separado una queja contra**  **la empresa acreedora?**  NÚMERO DE CUENTA



### Si usted elije “Sí”, iniciaremos por separado la gestión de una queja contra la empresa acreedora. Como resultado, se dará trámite a dos quejas en total: una contra la empresa de cobro de deudas y otra contra la empresa acreedora. LA MISMA EMPRESA QUE COBRA LA DEUDA

SÍ OTRA EMPRESA ACREEDORA

NO NO SÉ CONTESTE LAS PREGUNTAS 8 Y 9

PASE A LA PREGUNTA 10 PASE A LA PREGUNTA 10

**8a**

**9 8**  **7**

NOMBRE O IDENTIFICACIÓN DEL REPRESENTANTE TELÉFONO CALLE Y NÚMERO

CIUDAD PAÍS ESTADO CÓDIGO POSTAL NO SÉ EL NOMBRE DE LA EMPRESA

# 5 **DE** 

# 8

Usted debe proporcionar su nombre completo y los cuatro últimos dígitos de su número de Seguro Social para que la empresa pueda encontrar su expediente y responder a su queja.

**Datos de información**  **de contacto**

Vamos a usar estos datos para informarle sobre el estado de tramitación de su queja.



### Otro contacto

OPCIONAL

Utilice esta sección si desea que le informemos a otra persona sobre el estado de tramitación de la queja. NOMBRE NOMBRE

APELLIDO(S) APELLIDO(S)

CUATRO ÚLTIMOS DÍGITOS DE SU NÚMERO DE SEGURO SOCIAL

SUFIJO SUFIJO

EDAD Las empresas utilizan esta información para encontrar en sus registros el expediente del cliente y responder a las quejas. La omisión de estos datos puede demorar o imposibilitar la respuesta de la empresa. CORREO ELECTRÓNICO TELÉFONO

TELÉFONO 10

**11** CALLE Y NÚMERO

CALLE Y NÚMERO CIUDAD

CIUDAD PAÍS

PAÍS ESTADO

ESTADO CÓDIGO POSTAL

CÓDIGO POSTAL 

### Otros datos de **identificación**

OPCIONAL **10a** 

# Datos personales

# 6 **DE** 

# 8

ACTIVO

RESERVA

GUARDIA NACIONAL

EN RETIRO

VETERANO (EX COMBATIENTE)



### Datos personales **del integrante de las fuerzas**  **armadas El consumidor es** 

**o era:**
OPCIONAL (INDIQUE TODOS LOS QUE CORRESPONDAN)



### Historial de **servicio militar** ESCOJA UNA OPCIÓN
EN CADA COLUMNA 

### Hay algunas protecciones a las que se pueden acoger los militares y sus cónyuges y dependientes.

INTEGRANTE DE LAS FUERZAS ARMADAS (FF. AA.)

CÓNYUGE / DEPENDIENTE DE UN INTEGRANTE DE LAS FF. AA.



### Estado actual **Rama Rango** 

EJÉRCITO

MARINA
INFANTERÍA DE MARINA
FUERZA AÉREA

SERVICIO DE GUARDACOSTAS
SERVICIO DE SALUD PÚBLICA
ADMINISTRACIÓN NACIONAL DE OCÉANOS Y ATMÓSFERA E1 - E4

E5 - E7

E8 - E9

O1 - O3

O4 - O6

O7 - O10

W01 - CW5 CONTESTE LA PREGUNTA 12A

CONTESTE LAS PREGUNTAS 12A Y 12B

NOMBRE APELLIDO(S) SUFIJO

CALLE Y NÚMERO

CIUDAD PAÍS ESTADO CÓDIGO POSTAL 

# Historial militar

**12**

**12a**

**12b**

# 7 **DE** 

# 8

**La información proporcionada es verdadera a mi leal saber y entender. Entiendo que la CFPB no puede actuar como mi abogado, un tribunal o un asesor financiero.** 

FIRMA FECHA 

# Certificación

**Maneras de presentar este formulario**

**Otras maneras de presentar su queja**

**Por Internet** consumerfinance.gov/complaint **Por teléfono** (855) 411-2372 **Por correo** Oficina para la Protección Financiera Del Consumidor PO Box 4503, Iowa City, IA 52244 **Por fax** (855) 237-2392

# 8 **DE** 

# 8

La información que usted proporcione permitirá a la Oficina para la Protección Financiera del Consumidor (CFPB) atender su queja o consulta sobre las empresas y los servicios que supervisamos. La información sobre su queja o consulta (incluidos datos confidenciales) se puede poner a disposición de cualquiera de las siguen

tes partes:



# ▪ la empresa que es objeto de su queja;


# ▪ terceras partes, según sea necesario con el fin de obtener la información necesaria para atender la queja;


# ▪ tribunales, partes litigantes, abogados, entidades jurídicas o cortes administrativas, en el curso de un proceso judicial o administrativo, o el Departamento de Justicia;


# ▪ otros organismos o autoridades reguladoras, ya sean federales o estatales, para los fines establecidos por la ley o para los fines de cumplimiento de la ley, o


# ▪ contratantes, agentes y otras partes autorizadas por la CFPB para recibir esta información. Por medio de una base de datos de quejas, también podemos poner a disposición del público su queja o consulta (salvo los datos confidenciales).
El presente instrumento de recolección de datos está autorizado por la Sección 5493 del Título 12 del Código de los Estados Unidos (12 U.S.C. §5493).
No es obligatorio presentar una queja o proporcionar datos confidenciales (incluyendo su número de Seguro Social). Además, puede retirar su queja en cualquier momento. Sin embargo, si usted no incluye la informa

ción solicitada, es posible que la CFPB no pueda tomar acción en relación a su queja.

Número de control emitido por la Oficina de Administración y Presupuesto (OMB): 3170-0011
Utilizamos el presente formulario para recibir las quejas. Si usted no desea presentar una queja, no está obligado a llenar este formulario. Calculamos que se necesitan entre 7 y 10 minutos para llenar el formulario. El número de control emitido por la OMB para el formulario es 3170-0011 y tiene vigencia hasta el 30 de noviembre del 2014. ¿Tiene usted algún comentario o sugerencia? Envíenos un mensaje a PRA@cfpb.gov. 

# Aviso sobre la Ley de Privacidad

**Aviso sobre la recolección de información del consumidor**

# CONSUMER RESPONSE CENTER AGENT CALL SCRIPTS
Version 5.01 (Presented in script # order)



# March 1, 2015

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes

i1 Good < time of day >! Thank you for calling the Consum e 

### r Financial Protection Bureau.

Does record auto

- populate from IVR? <Select YES or NO> button Note: Script page number NOT visible.

i2 {If Caller punched in case number on phone and the case auto populates.}
Can you confirm that you are calling about a case number ending in “ xxxx ”? Use the last 4 digits of the case number for verification.
Verify the caller: I need to ask a couple of questions to verify your identity

.

- What is your name? Confirm contact or complainant's name.

- Can you verify the address, including zip code and email address?
<Go to Closing> button <Beginning> button i2 i3 Closing for existing cases }
If Zip code has not been provided:
If you don’t mind, can I get your Zip code for tracking purposes?
Zip Code <Fill in Zip Code>

Thank you for calling the Consumer Financial Protection Bureau. You can also find more information at consumerfinance.gov

. <Beginning> button <Previous> button i3 i4 {If the case does not auto populate.}
Are you calling in reference to a complaint you already have on file? * <Select YES or NO> button
If the caller speaks Spanish transfer to 330002.

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes <Beginning> button i4 i5 {If case does not auto populate AND caller says case is on file}
Verify the caller: I need to ask a couple of questions to verify your identity.

- Can you provide the case number?

- What is your name? Conduct Search and then confirm contact or complainant’s name.

- Can you verify the address, including Zip code and email address?

- If no address: What is the email address provided for the case?
<Go to Closing> button <Beginning> button i5 02 To get started is there a phone number where I can reach you if we get disconnected?

< Fill in phone number >
What product or service can I help you with today? HT: Don’t forget to CONFIRM THE PURPOSE OF THE CALL as soon as callers tell you their issue or reason for the call.
High Level Product* <Fill in HL Product from drop down box>
{ Dynamic, if High Level Product = Payday loan} Does this concern debt collection of a payday loan?* <click on YES or NO button>
{if YES is selected, the following helper text will display} NOTE: if “Yes” is selected, the product will be changed to “Debt collection” with sub

- product “Payday loan”

{Dynamic, if Product /sub

- product = Other financial service/debt settlement } Does this concern a problem with a debt collector?* <click on YES or NO button>

{Dynamic, if Product /sub

- product = Other financial service/credit repair} Does this concern a problem with your credit report or score?* <click on YES or NO button> Default Value “Does this concern ... payday loan?*” = NO

Default Value “Does this concern..debt collector?*” = NO

Default Value “Does this concern..credit report?*” = NO

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes

< PRODUCT SELECTION HINTS (Click here ) > button

{Dynamic, if agent clicks to open Product selection hints}

1

) Bank account or service for checking and savings accounts, debit cards, CDs, cashing a check without an account or other bank services. 2) Credit card 3) Consumer loan for vehicle loans and leases, installment loans (e.g. medical, appliance, vacation, funeral) , title loans, pawn loans or a personal line of credit. 4) Credit reporting for incorrect information on a credit report, problems with a credit reporting company's investigation, improper use of a credit report, inability to obtain a credit report, credit monitoring or identity protection services. 5) Debt collection for problems related to attempts to contact you by a collection company regarding debt owed, or alleged to be owed. 6) Money transfers for transfers of money within the U.S. and internationall y. 7) Mortgage for mortgages, second mortgages, home equity lines of credit, reverse mortgage, etc. 8) Non

- product inquiry for any question that is not about one of the products listed above

. 

### 9

) Other financial service for non

- bank check cashing services, credit repair (EXCEPT for problems with a credit report}, debt settlement (EXCEPT for a problem with a debt collector), foreign currency exchange, money orders, refund anticipation checks and traveler’s or cashier’s ch ecks. 10

) Payday loan for all problems related to payday loans, EXCEPT those concerning lender collection practices on a payday loan, which should be identified as a “Debt collection” complaint 11

) Prepaid card for general reloadable prepaid cards, government benefit payment cards (e.g unemployment, social security) , EBT cards (e.g. WIC,TANF,SNAP) , ID prepaid cards (e.g. students), transit cards, gift or merchant cards, mobile wallets, payroll cards, and other special purpose cards. 12

) Student loan for Federal (Stafford, Direct, Consolidation, PLUS, Perkins), Non

- federal (e.g. private, alternative, or other student loan). HT: If the caller is asking about a product not mentioned above, go to and follow Answer 1836. Afterwards, click “Go to closing” and select the product/sub

- product that best fits the topic.

If the caller is speaking Spanish or has been transferred to a Spanish speaking agent: Could you confirm that you would like to receive written communication from us in Spanish ?* ( If 

### Yes, Default value: Language Preference: ENGLISH

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes Select Spanish.) <Select English (US) or Spanish>
<Go to Closing> button Use the “Go to Closing” button on this screen only if you are saving a partial case , i.e. a call was disconnected part way through taking a complaint.



### <Previous> button <Next> button 2 03 Thank you. I’ll be happy to help you.
Choose “Question” or “Complaint” based on information provided. If you are uncertain ask consumer.
Do you want to file a complaint or do you need help with a question?*

< Select Question or Complaint > button
<Beginning> button <Previous> button <Next> button 3 04 Deleted

05 Deleted

6 [standard script page] {If caller has a Question}
If the consumer has not already provided their question, say: I would be more than happy to research your inquiry to try and provide you an answer. What specific question did you have?

Search the Knowledgebase using keywords. If the answer is not readily available in the Knowledgebase, check the Consumer Action Handb ook. If product falls outside CFPB scope, refer to Knowledgebase 1836.

OR Go to consumerfinance.gov/askcfpb and search for an answer.
If information is in CFPB scope and still not found: Unfortunately, I can't find any information about your specific question. To request that your question be

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes
added to our database of FAQs about financial issues, visit on our website at consumerfinance.gov/askcfpb. Ask CFPB is an interactive online tool for helping consumers find clear unbiased answers to financial questions. If you select the option to have us contact you by email, we’ll let you know if your question is answered and added to Ask CFPB

. You also always have the option to continue with a comp laint if desired. HT: CFPB Phone # : 1 (855) 411

- CFPB (2372)
Would you like to continue with either of these? If consumers choose to submit their questions , offer to guide them to the Add a New Question button on our website. (Agents may also offer to submit it online or through our Propose button for consumers if requested. If consumers wish to submit complaints , click “ Click if consumer wants to file complaint ” button. If consumers say no, click “ Go to closing ” button.
<Go to Closing> button <Click if Consumer wants to file Complaint> button <Beginning> button <Previous> button 6 6 [2015 customer service survey page – temporary language highlighted ] {If caller has a Question}
If the consumer has not already provided their question, say: I would be more than happy to research your inquiry to try and provide you an answer. Also, at the end you’ll have a chance to take a short survey to help us improve this service. Now, w hat specific question did you have?

Search the Knowledgebase using keywords. If the answer is not readily available in the Knowledgebase, check the Consumer Action Handbook. If product falls outside CFPB scope, refer to Knowledgebase 1836.

OR Go to consumerfinance.gov/askcfpb and search for an answer.
If information is in CFPB scope and still not found: Unfortunately, I can't find any information about your specific question. To request that your question be added to our database of FAQs about financial issues, visit on our website at consumerfinance.g ov/askcfpb. Ask CFPB is an interactive online tool for helping consumers find clear unbiased answers to financial questions. If you select the option to have us contact you by email, we’ll let you know if your question is answered and added to Ask CFPB

. You also always have the option to

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes continue with a complaint if desired. HT: CFPB Phone # : 1 (855) 411

- CFPB (2372)
Would you like to continue with either of these? If consumers choose to submit their questions , offer to guide them to the Add a New Ques tion button on our website. (Agents may also offer to submit it online or through our Propose button for consumers if requested. If consumers wish to submit complaints , click “ Click if consumer wants to file complaint ” button. If consumers say no, click “ Go to closing ” button.
<Go to Closing> button <Click if Consumer wants to file Complaint> button <Beginning> button <Previous> button 6 07 {If HL product is Credit Card} To best assist you, I need to ask you a few questions.
Does your card say “debit” or “check card” on the front of it? < Select YES or NO> 7 08 {If product says Debit/Check card} Since your card says [debit/check] card, is it associated with your checking account or your savings account?

Select Product *. <Select HL Product or HL and Sub

- Product from drop down> 8 09 DELETED

9 April 2014: Deactivated Script

10 DELETED

10 April 2014: Deactivated Script

11 DELETED April 2014: Deactivated Script

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes

11 12 DELETED

12 April 2014: Deactivated Script

13 DELETED

13 April 2014: Deactivated Script

14 DELETED

14 April 2014: Deactivated Script

1 5 DELETED 15 16 DELETED

16 April 2014: Deactivated Script

17 DELETED

17 April 2014: Deactivated Script

18 If consumer has NOT identified the type of student loan, then say : “Are you calling in regards to a federal
or non

- federal student loan?"

___ Federal (Say: “FFEL, Stafford, Direct, Consolidation, PLUS, Grad PLUS, NDSL Perkins”) __ Non

- Federal (Say: “Private, Alternative, Other Student Loan:) __ Consumer is not sure
<Beginning> button <Previous> button 18 19 {If caller has a Federal Student loan}
Currently the CFPB is only receiving complaints for non

- Federal student loans. Since your loan is a federal loan, the Department of Education will be able to further assist you.
Provide the contact information for the Department of Education and then cold transfer.

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes

Department of Education Federal Student Aid Ombudsman: http:// studentaid .ed.gov 1 (877) 557

- 2575
Before you file a complaint you may want to click on Repay Your Loans found in the top menu for information about locating your servicers, learning more about payment, deferment and forbearance options or help with disputes.
Thank you for contacting the Consumer Financial Protection Bureau, there is more information about financial products on our website consumerrfinance.gov . May I place you on a brief hold while I connect you?

19 20 {If caller is not sure if their loan is private or federal }
Currently the CFPB is only receiving complaints for non

- federal student loans.
To check whether your student loan is federal or non

- federal, I can transfer you to the Department of Education or refer you to the National Student Loan Data System for Students website.

Phone: 1 (800) 4

- FED

- AID (1 (800) 433

- 3243) Website: https://www.nslds.ed.gov
Once you are on the NSLDS website, select “Financial Aid Review” for a list of all federal loans made to you. Click 'Accept' twice and then you will be prompted to enter personal information. Check each individual loan to see who the servicer is for that loan (this is the company that collects payments from you).
A few helpful tips for federal and non

- federal loans: Federal loans: • Pro bably have a name like Stafford, PLUS, Direct, or Perkins Non

- federal loans: • Issued by a bank, credit union, your school, or other lending institution • Might use names like “private” or “alternative” • Issued by a non

- profit or state agency • If you’re not sure whether you have non

- federal loans, contact your school’s financial aid office since they may have this information on file.

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes
20 21 { If caller is fili ng a Credit reporting complaint}
Which of these best describes your issue?* {Dropdown list with issues and sub issues}

• Incorrect Information on Credit Report

o Information is not mine

o Account terms

o Account status

o Personal information

o Public Record

o Reinserted previously deleted information

• Credit reporting company’s investigation

o Investigation took too long

o No notice of investigation status/result

o Inadequate help over the phone

o Problem with statement of dispute

• Improper use of my credit report

o Report improperly shared by CRA

o Received marketing offer after opting out

o Report shared with employer without consent

• Unable to get credit report/score

o Problem getting my free annual report

o Problem getting report or score

o Credit monitoring or identity protection

• Problem cancelling or closing account

o Billing dispute

o Receiving unwanted marketing /advertising

o Account terms and changes

o Problems with fraud alerts 21 SCRIPT DE ACTIVATED AS PART OF THE DEBT COLLECTION RELEASE (July 2013)

22 { For HL Product = Credit Reporting only} May I have the name of the company you are calling about? {Dropdown list with Companies }

• Equifax

• Experian

• TransUnion

• Certegy Check Services

• Chex Services

• CoreLogic Teletrack SCRIPT DE ACTIVATED AS PART OF THE DEBT COLLECTION RELEASE (July 2013)

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes

• CoreScore Credit Report

• DataX

• Factor Trust

• ID Analytics

• Innovis

• L2C \ Microbilt

• PRBC / MicroBilt

• TeleCheck

• Other {If the caller says the company is not on the list and the Agent selected Other in the preceding drop down} If Other, company name (as stated by Consumer)* <Fill in Company> Address(1) <Fill in Street Address, optional> Address(2) <Fill in Street/other address, optional> City <fill in City, optiona l> State <Fill in from Drop Down List, optional> Zip Code <Fill in zip +4, optional> Telephone <fill in phone #, optional> Website <fill in web site, optional>

Did you file a dispute about the issue with the credit reporting company and receive a final response?* <Select YES or NO> {If YES, then fill in this question} Original Dispute Case Number <Fill in #, optional> 22 24 Are you calling *

__ about your personal mortgage or on behalf of a family member or friend? __ on behalf of a mortgage related company?
<Beginning> button <Previous> button <Next> button 24 25 {If the person is calling “on behalf of a mortgage related company” ( from S#24)}
We are not able to address industry questions over the phone, but I would be happy to provide you with an email address where you can submit your question or concern.

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes

The email address is cfpb_respainquiries@cfpb.gov (Note: ONLY for industry use)

.
<Go to Closing> button
<Beginning> button <Previous> button 25 26 If consumer has already identified one of the issues below, confirm and select their issue below.
If consumer has NOT identified the reason for calling then say : "I'd be happy to help you with that. Are you unable to make payment and concerned about foreclosure, OR do you have a mortgage complaint about a specific institution OR do you have general questions about the mortgage process?" Based on consumer's response, select option below.
__ 1) Has a concern about foreclosure or is unable to make payments __ 2) Has a question about their loan or the mortgage process __ 3) Has a mortgage related complaint regarding a specific institution
<Beginning> button <Previous > button <Next> button 26 4/13/13 Note : Remove

27 Is this about something you observed while working for a financial institution or financial service provider?* < select YES or NO >

If the caller needs clarification : By asking this question we are identifying ‘whistleblowers’ and ‘tipsters’. If you work at a financial institution or financial service provide r you may have specialized industry knowledge

. {Dynamic, if YES to whistleblower}

Since you’ve answered “yes” that this is something you observed while working for a company that offers financial products or services, your information will not be sent to the company you are complaining about. Is there any relationship between your employer and the company you are complaining about that would be a reason that you would not want your complaint sent to the company? Default Values :

• Whistleblower = NO

• Send to Company = YES

4/2014

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes

HT: If the consumer doesn’t object to sending the complaint to the company then change the whistleblower question to ‘NO’ and continue taking the complaint
If consumer says there is a reason to not send the information to the company refer to the Whistleblower Hotline (855) 695

- 7974 or CFPB_Whistleblower@cfpb.gov
What Happened? <fill in What Happened explanation, optional>

<Save Whistleblower Case> button <Beginning> button

D o you want the CFPB to send your complaint to the company?* <Select YES or NO>

{Dynamic, if No to Send to Company } For most complaints, the CFPB forwards some information to the company you identify. If you do not want us to send any information to them, 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.

<Beginning> button <Previous> button <Next> button 27 28 Before we begin, let me describe the complaint process to you so you will understand what to expect.
We've tried to make it as easy as possible to submit a complaint. The best way to submit is on our website consumerfinance.gov . This is the most time

- effective for you, as well as the most accurate for us. You can also submit a complaint by phone, mail, or fax. However, if you plan on attaching any supporting documentation, you may want to submit online or by fax or mail.
Once you have submitted your complaint, it will be sent to the company for review and they will have 15 calendar days to respond to your complaint. If you provide an email address, you will receive electronic notices about your complaint and will be able to access that information online at consumerfinance.gov

. Your email address will serve as your login ID and you will need to create a password the first time you login.
{If Product / Sub Product = Money transfer/International ...} It’s a good idea to also contact the company as soon as possible if you think it ma d e a mistake.

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes Information about how to contact the company may be on the receipt you received.
Which method do you prefer to submit your complaint? __ Web __ Phone __ Fax/Mail/Paper Form
<Beginning> button <Previous> button 28 29 I will be happy to take your complaint over the phone. I do need to inform you that you will not be able to attach any documentation to your complaint after I open a case for you today. If you have documentation to add to your complaint, you may complete your complaint on our website and attach your documents, or submit your complaint to CFPB by fax or by mail. Would you still like to submit your complaint by phone today?
Before we begin, I need to read to you official disclosure statements to make sure that you understand your rights and what we can provide as a part of this process. After I read the statements, I will ask you if you understood.
The Paperwork Reduction Act is a federal law that requires the approval of certain federal questionnaires. The Office of Management and Budget has approved these questions under the Paperwork Reduction Act. On average, answering these questions takes about 10 minutes. The length of time to complete your complaint depends on the complexity of the complaint.

Also , a federal law called the Privacy Act directs how the federal government (or the CFPB) collects, keeps and shares your personal, private Information - including the personal information contained in your answers to these questions. To understand how and when your information may be shared, you can read the Privacy Act Statement on our website, consumerfinance.gov

. The Consumer Financial Protection Bureau cannot act as a court of law or as a lawyer on your behalf, and we cannot give you legal or financial advice.
Do you understand these disclosures as I have read them to you? *

< select YES or NO > {Dynamic, Pop Up message if No } I understand parts of the disclosure can be confusing. However without your acknowledgement of the disclosure I won’t be able to continue through the complaint form. Do you have some questions about the

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes disclosure that I could answer to make you more comfortable? <click pop up to close>
Do you now understand and agree to continue? <select YES or NO>
{If NO, go to closing as an Inquiry} Additional References: Privacy Act Statement Knowledgebase answer 230 Process the complaint will follow: Knowledgebase answer (not yet developed)

<Beginning> button <Previous> button <Next> button 29 30 Do you want to submit this form to CFPB anonymously?*

< select YES or NO >
{Dynamic, if YES to Anonymous question} For most complaints, the CFPB forwards some information to the company you identify. You can submit 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.

Dynamic, if NO to Anonymous question} OK, I’ll need to get your contact information. May I have your name please?
Check for existing contact. Specifically ask for email address when creating the contact record. If existing contact found, follow established identity verification procedures before proceeding to the next page (Knowledgebase 998).

Contact* <connect to Contact Search record> Salutation <choose one, optional> First Name * < update name, optional > Middle Name <update name, optional > Last Name * < update name, optional > Suffix <fill in suffix> Anonymous question default value = NO

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes
Address* < click on Edit hyperlink, update pop up, optional >
Primary Phone <update phone , optional> {Use arrow down button to select phone type (e.g. mobile, fax etc.)}
Email <update email, optional> {Use arrow down button to select email type (e.g. email, email alt1, etc.)}
{Dynamic once contact is entered .}

VERIFY THE FULL MAILING ADDRESS ABOVE. Click on Address < Edit >. Is the Street, City, Country, State/Prov., AND Postal code populated? If not, update these values before continuing. * <Select YES or NO> buttons

<

Beginning> button <Previous> button <Next> button 30 31
Product: Credit card, Consumer loan (incl. Title & Pawn), Bank Acct/Svc. Student loan, Mortgage, Money transfer {Skip this script for HL Product = Debt collection}
{For HL Products other than Credit Reporting & Payday; allows both ‘yourself ‘ AND ‘someone’ else to be selected concurrently} Are you filing on behalf of yourself? * < select YES or NO > On behalf of someone else? < Select YES or NO >
{Dynamic, if HL Product = Money Transfers, ask the following question(s) depending on the answers provided to the 2 questions show above for this script page}
If the answer to ‘Are you filing on behalf of yourself?’ = YES A re you: < select one: __ Sende r __ Recipient __ Filing on behalf of someone else>

If the answer to “On behalf of someone else?” = YES Is the person on whose behalf you are filing this complaint <select one: __ Sender

___ Recipient >
{If the Contact is the Sender or the Recipient, Contact name and address (not phone or email) should be copied to the Sender or Recipient field accordingly, upon saving the case}

{Dynamic if filing on ‘behalf of someone else.} Default Values:

• Are you filing...yourself? = YES

• Are you filing..someone else? = “Choose”

• Are You = Choose

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes Relationship (to the someone else )* < select one > __ Family Member __ Friend __ Attorney __ Government Employee __ Advocate __ Housing Counselor __ Other
If you are filing a complaint on behalf of someone else, we may need this person’s signed, written permission to take action. Salutation <choose one, optional> First Name* <fill in name> Middle Name <fill in name, optional> Last Name* <fill in name> Suffix <choose one, optional> Country* <choose one, US default> Address 1* <fill in address> Address 2 <fill in address, optional> City* <fill in city> State* <choose state code, REQUIRED if US = Country> Zip code* <fill in zip, REQUIRED if US =Country> Phone <fill in phone, optional> Email <fill in email, optional>

<Beginning> button <Previous> button <Next> button 31 31
Product : Payday, Prepaid card, Other financial service {For HL Products = Payday loan, Other financial service, Prepaid} Are you filing on behalf of yourself? * < select YES or NO > On behalf of Someone Else? < Select YES or NO, cannot be YES if prior question = YES >
{Dynamic if filing on ‘behalf of someone else = YES} Relationship (to the someone else )* < select one > __ Family Member __ Friend __ Attorney Default Values:

• Are you filing...yourself? = YES

• Are you filing..someone else? = “Choose”

Default Values:

• Relationship = “Choose”

• Country = “US”

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes __ Government Employee __ Advocate

__ Housing Counselor __ Other
If you are filing a complaint on behalf of someone else, we may need this person’s signed, written permission to take action. Salutation <choose one, optional> First Name* <fill in name> Middle Name <fill in name, optional> Last Name* <fill in name> Suffix <choose one, optional> Country* <choose one, US default> Address 1* <fill in address> Address 2 <fill in address, optional> City* <fill in city> State* <choose state code, REQUIRED if US = Country> Zip code* <fill in zip, REQU IRED if US =Country> Phone <fill in phone, optional> Email <fill in email, optional>

<Beginning> button <Previous> button <Next> button 31 32 Restate and confirm the product/sub

- product with the consumer or ask them directly based on the options in the product/sub

- product field below.

Product/Sub

- product* < fill in HL product and sub

- product from product drop down list>

{Dynamic, if Product = Student loan} 

### Currently the CFPB is only receiving complaints for non

- federal student loans.

Which of these best describes your complaint issue ?*

<

fill in Issue from the drop down list related to the Product/Sub

- product chosen >
{ Dynamic based on HL Product/Sub

- product selecte d

} Jan 2014 Note : S#32 Student Loan Issues changed. Old issues continue to appear, but Agent will receive pop

- up error message if selected.

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes
{ Mortgage } {If Product / Sub

- product = Other Mortgage then add dynamic extra question} Mortgage – Type Other* <fill in text box>

{For all mortgage sub

- products the following Issue helper text also appears} Applying for the loan Application, originator, mortgage broker Receiving a credit offer Credit decision/Underwriting Signing the agreement Settlement process and costs Making payments Loan servicing, payments, escrow accounts Problems when you are unable to pay Loan modification, collection, foreclosure

{Bank account or service s} Account opening, closing or management Confusing marketing, denial, disclosure, fees, closure, account access, interest, statements, joint accounts Deposits and withdrawals Availability of deposits, withdrawal problems and penalties, unauthorized transactions, check cashing, payroll deposit problems, lost or missing funds, transaction holds Using a debit or ATM car d Disputed transaction, unauthorized card use, ATM or debit card fees, ATM problems Making or receiving payments Problems with payments by check, card, phone, or online, unauthorized or fraudulent transactions. Problems caused by my funds being low Overdraft fees, late fees, bounced checks

{Consumer loan/ Vehicle loan, vehicle lease, installment loan } Shopping for a loan or lease Sales tactics or pressure, credit denial, confusing Taking out the loan or lease Term changes (mid

- deal changes, changes after closing, etc.), required add

- on products, trade

- in Managing the loan or lease Billing, late fees, damage or loss, Insurance (GAP, credit etc.) privacy Problems when you are unable to pay R

epossession, deficiency, bankruptcy, default

{Consumer l oan / Personal line of c redit } Shopping for a credit line Confusing advertising or marketing, credit denial

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes Account terms and changes Term changes (rates, fees, etc.), access, line reduction, suspension or termination Managing the line of credit Billing, late fees, privacy Problems when you are unable to pay R

epossession, deficiency, bankruptcy, default

{ Consumer loan/ Pawn l oan} Charged unexpected fees or interest
Can’t stop charges to bank account
Received a loan I didn’t apply for
Applied for loan/did not receive money
Charged bank acct wrong day or amt.
Payment to acct not credited

Can’t contact lender
Lender sold the property
Lender damaged or destroyed property

{ Consumer loan / Title Loan} Charged unexpected fees or interest
Can’t stop charges to bank account
Received a loan I didn’t apply for
Applied for loan/did not receive money
Charged bank acct wrong day or amt
Payment to acct not credited

Can’t contact lender
Lender repossessed or sold the vehicle

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes
Lender damaged or destroyed vehicle

{Credit c ard} - no Helper Text

{Credit r eporting - NO Helper Text needed because scripting flow skips this. Issue and Sub

- Issue has been previously selected}

{ For Other financial service/ Check cashing, Debt settlement, Credit repair}, Advertising and marketing

Customer service/Customer relations

Disclosures

Excessive fees
Unexpected/Other fees

Fraud or scam

{ For Foreign currency exchange} Advertising and marketing

Customer service/Customer relations

Disclosures

Excessive fees
Unexpected/Other fees
Incorrect exchange rate

Fraud or scam

For Other financial service/ Travelers/Cashiers ck,, Money order, Refund antic loan} Advertising and marketing

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes

Customer service/Customer relations

Disclosures

Excessive fees
Unexpected/Other fees

Lost or stolen

Fraud or scam

{For Money t ransfers} Money was not available when promised
Wrong amount charged or received Transfer amount, fees, exchange rates, taxes, etc.
Incorrect/missing disclosures or info

Other transaction issues Unauthorized transaction, cancellation, refund, etc.

Other service issues Advertising or marketing, pricing, privacy, etc.

Fraud or scam

{ For Prepaid Card} Managing, opening, or closing account

Fees

Unauthorized transactions/trans. issues
Advertising, marketing or disclosures
Adding money
Overdraft, savings or rewards features

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes

Fraud or scam

{Student l oan} Getting a loan Denial, confusing advertising or marketing, sales tactics or pressure, financial aid services, recruiting, fraudulent loan.
Can’t repay my loan Deferment, forbearance, default, bankruptcy, payment plan, refinancing.
Dealing with my lender or servicer Making payments, getting information about my loan, managing my account.

{Debt c ollection}

Communication tactics Frequent or repeated calls; called outside of 8am

- 9pm; used obscene, profane or other abusive language; threatened to take legal action; frequent or repeated calls; called after sent written cease of communication notice
Continued attempts to collect debt I do not owe Debt was discharged in bankruptcy; debt resulted from identity theft; debt was paid; debt is not mine

Disclosure verification of debt Did not receive notice of right to dispute; did not provide enough information to verify debt (i.e. amount of debt and name of creditor is owed); did not disclose communication was an attempt to collect debt
Improper contact or sharing of information Contacted me after I asked not to; contacted my employer after I asked not to; contacted me instead of my attorney; talked to a third party about my debt.
False statements or representation Attempt to collect wrong amount; impersonating attorney, law enforcement or government official; indicate committing crime by not paying debt; indicate should not respond to lawsuit.
Taking or threatening to take an illegal action Threaten to arrest me or take me to jail if I do not pay, threaten to sue me on debt that is too old to be sued on; sued me without properly notifying me of lawsuit, sued me when I did not live or did not sign for the debt; actual or attempt to collect exempt funds (i.e. social security, worker’s compensation, unemployment or child support; actual or attempt to seize property.

{Payday loan}

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes Charged fees or interest I didn’t expect Consumer was charged fees or interest that he or she did not expect.

Can’t stop charges to bank account C

onsumer was unable to stop the lender from charging his or her bank account

Received a loan I didn’t apply for Consumer received a loan that he or she did not apply for.
Applied for loan / did not receive money Consumer applied for a loan but did not receive money.
Charged bank acct wrong day or amt The lender charged the consumer’s bank account on the wrong day or in the wrong amount.
Payment to acct not credited The lender did not credit a payment to the consumer’s account.

Cannot contact l ender Cons umer was unable to contact the l ender.

<Beginning> button <Previous> button <Next> button 

### 32 33 {Dynamic, If the product is Mortgage AND the issue is “Loan Modification, collection, foreclosure”}
Are you concerned about losing your home to foreclosure? <Select Yes or NO>

{Dynamic section if Answer = YES} Have you missed payments or are you in default on your mortgage? This includes if your mortgage company believes you are in default or have missed payments, even if you believe your mortgage company is in error. <select YES or NO>

Is there a date that is scheduled fo r the foreclosure sale of your home ? If a foreclosure sale has been scheduled, you might have received a Notice of Sale or Order Setting Sale.

< select YES or NO > {Dynamic if preceding answer is YES} What is the date of the scheduled foreclosure sale?

< select date from RN calendar > Default Values:

• Are you concerned about losing your home.... = Choose

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes

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? <Select Yes or NO>

<Be ginning> button <Previous> button <Next> button 33 34 {Credit c ard product only} If you lost money, how much money did you lose? <fill in $$ amount>
When did this happen? < choose date from calendar>
Have you done any of these things to try to resolve this issue? <select one or more> Contacted the Company directly <select YES or NO> Contacted the Consumer Financial Protection Bureau <select YES or NO> Hired an Attorney <sel ect YES or NO> Contacted Gov’t Agency <select YES or NO> Filed Legal Action <select YES or NO>
<Beginning> button <Previous> button <Next> button 34 35 REMOVED (Discrimination scripting)

35 REMOVED BASED ON CR367 (Aug. 2013)

36 Describe your complaint. Include facts about what happened and any steps you have taken to resolve the issue.

Dynamic, HL Product = Payday l oan}
{If Issue = Charged unexpected fees or interest} Please include in your explanation the amount of fees or interest that was paid.
{If Issue = Cannot stop charges to bank account} Please include in your explanation the name of the bank

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes

and the state in which this bank is located.
{If Issue = Charged bank acct wrong day or amt

. } Please indicate in your explanation whether this

r esulted in an overdraft fee.

If consumer attempts to provide sensitive personal information in this description, note that we collect account numbers and other sensitive information later in the process in order to have it in a separate place and help protect their privacy

. Enter the company name provided by the consumer. If there is an exact match, you may select from the list. Otherwise, enter the full name as provided by the consumer. If clarification is needed, ask or confirm what company name shows up on their statement/receipt. If the consumer does not know the company, enter Unknown.

{Dynami c, Hidden if HL Product = Debt collection } Company (As stated by consumer)* < Fill in Company Name >
I am going to be typing everything you say verbatim. Would you mind speaking at a moderate pace? Enter complaint description (What Happened).* <Enter What Happened >
{Dynamic, applies to HL Product = Money t ransfer} How much was transferred? <fill in amount> Amount MUST be in 0.00 format. Is that amount in U.S. dollars or other currency?<Select Currency Type, USD default value>

D ate of transfer? <fill in date> If the date provided is after today’s date say, “Can you please confirm that the date of the transfer related to this complaint is < read the date you recorded ”>?” When money was sent

.
What was the transfer ID or transaction number? <fill in #> If caller does not know what transfer ID or transaction number is : The Transfer ID or transaction number may be found on the money transfer receipt?
Date the funds were promised <fill in date from calendar> If before the Date of transfer say : “ The date you provided is prior to the Date of transfer. Let’s confirm both dates to make sure I record them correctly.”

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes When funds expected.
When did the issue you just described occur? <fill in date> If after ‘today’s date” say: “The issue must have occurred today or in the past. Can you verify that date for me?” What is the amount of the error, if any? <fill in $$ amnt> Amount MUST be in 0.00 format

. Is that amount in U.S. dollars or other currency? <fill in currency, default to US>

<Beginning> button <Previous> button <Next> button 36 37 {ALL PRODUCTS} What do you thin k would be a fair resolution?* < Enter resolution?>
If consumer attempts to provide sensitive personal information in this description, state: "We collect account numbers and other sensitive information later in the process in order to have it in a separate place and help protect your privacy."


### <Beginning > button <Previous> button <Next> button 37 38
Product: Money Transfer {HL Product = Money Transfer for SENDING INFORMATION} Confirm that the company listed is the company that provided the money transfer service and obtain the additional information on this page.
What company is this complaint about?
[Company Name Displayed, editable]* Address 1 <fill in street address, optional> Address 2 <fill in street address, optional> City <fill in city name, optional> State <Fill in State 2

– digit code from drop down list, optional> Zip code <fill in zip orzip+4 for US addresses, optional, >

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes Country < Fill in country, Optional >
If the transfer was done from an account with this company, can you provide the Account number?
Account or Loan number (or Social Security number for Student Loans) <Fill in account number> Only ask for Social Security number if the Product is Student Loan.

If the consumer is concerned about providing account information: We use unique information about the account to verify that we have the right person to provide to the company and to help make sure the company reviews the correct account information. The more information you provide, the easier it will be to review and process the complaint



### <Be ginning> button <Previous> button <Next> button 38 38
Product : Mortgage,
Student Loan,
C onsumer loan (except Title and Pawn loans), 

### Credit card,
Bank Acct/Svc. Prepaid card
Other financial service {Dynamic depending on HL Product

--- DOES NOT INCLUDE HL Product= Payday loan, Money transfers, Comer loan/Pawn & Title, Debt collection}

{Mortgage} Ask for PROPERTY ADDRESS. Is the Account/Billing/P roperty address same as the primary contact’s address? <select YES or NO> {If NO} Address1* <fill in street address> Address2 (fill in address, Optional> City* < Fill in city name > State * < Fill in State 2

– digit code from drop down list > Zip Code* < fill in zip orzip+4 > Country* < fill in country from drop down list >
Account or Loan number (or Social Security number for Student Loans) Only ask for the Social Security number if the Product is Student Loan. <fill in number, Optional>

{Credit c ard} Ask for BILLING ADDRESS. Is the Account/Billing/Property address same as the primary contact’s address? <select YES or NO> Default values :

• Is Account/Billing/Property Address...? = YES

• Prop/Billing Address State = Choose

• Prop/Billing Address Country = US

• Company State = Choose

• Company Country = US

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes {If NO} Address1* <fill in street address> Address2 (fill in address, Optional> City* < Fill in city name > State * < Fill in State 2

– digit code from drop down list > Zip Code* < fill in zip orzip+4 > Country* < fill in country from drop down list >
Account/Loan Number or Social Security Number < Fill in number, Optional > How does the name appear on the credit card/credit report? < fill in name, Optional >

{Bank acct/svc, Prepaid card, Other financial service } Ask for ACCOUNT ADDRESS. Is the Account/Billing/Property address same as the primary contact’s address? <select YES or NO> {If NO} Address1* <fill in street address> Address2 (fill in address, Optional> City* < Fill in city name > State * < Fill in State 2

– digit code from drop down list > Zip Code* < fill in zip orzip+4 > Country* < fill in country from drop down list >
Account or Loan number (or Social Security number for Student Loans) <fill in number, Optional> Only ask for the Social Security number if the Product is Student Loan.

{Cons umer loan } Ask for BILLING ADDRESS. Is the Account/Billing/Property address same as the primary contact’s address? < select YES or NO > {If NO} Address1* <fill in street address> Address2 (fill in address, Optional> City* < Fill in city name > State * < Fill in State 2

– digit code from drop down list > Zip Code* < fill in zip orzip+4 > Country* < fill in country from drop down list >
Account or Loan number (or Social Security number for Student Loans) Only ask for the Social Security

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes
number if the Product is St udent Loan. <fill in number, Optional>

{Student Loan} Ask for BILLING ADDRESS. Is the Account/Billing/Property address same as the primary contact’s address? < select YES or NO > {If NO} Address1* <fill in street address> Address2 (fill in address, Optional> City* < Fill in city name > State * < Fill in State 2

– digit code from drop down list > Zip Code* < fill in zip orzip+4 > Country* < fill in country from drop down list >
Account or Loan number (or Social Security number for Student Loans) Only ask for the Social Security number if the Product is Student Loan. <fill in number, Optional> Social Security number MUST be entered in the format ###

- ##

- ####.

{Credit r eporting - INACTIVE } Name on credit report <fill in first middle last> Social Security Number < Fill in number in xxx

- xx
- xxxx format > Date of Birth < mm/dd/yyyy format > Name: Insert in First Middle Last order. Social Security Number: Enter as xxx

- xx - xxxx. Date of Birth: Enter in mm/dd/yyyy format only.
Social Security number MUST be entered in the format ###

- ##

- ####.

{All products} What company is this complaint about? COMPANY ADDRESS Company (As stated by consumer)* <fill in, editable> Address 1 <fill in street address, Optional> Address 2 <fill in street address, Optional> City < Fill in city name, Optional > State < Fill in State 2

– digit code from drop down list, Optional >

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes Zip < Fill in zip + 4, Optional> Country < choose from drop down, “Choose” Default> {Dynamic, HL product = Other financial service, Prepaid card} Phone num ber <Fill in company phone #,Optional>

If the consumer is concerned about providing account information : We use unique information about your account to verify that we have the right person to provide to the company and to help make sure the company reviews the correct account information. The more information you provide, the easier it will be to review and process your complaint.


### <Beginning> button <Previous> button <Next> button 38

38
Product: Payday loan
Consumer loan / Title and Pawn Loans {Dynamic, HL Product = Payday loan

, Consumer loan /Title Loan, Pawn Loan}

Where did you get the loan? <Select “In person / at a store” or “Online”> If consumers indicate that they applied online but picked up their loan in person, select “In person / at a store”
{ Dynamic, if “In person / at a store” selected} In which state is the store located? <Select US state, dropdown list>

If the consumer asks why we need this information, say “T his is important because di fferent states have different laws for payday loans.”
{ Dynamic, if “Online” selected} What is the website you used to apply for the payday loan? <Fill in web URL>
What company is this complaint about? COMPANY NAME & ADDRESS Company (As stated by consumer)* <fill in, editable> Address 1 <fill in street address, Optional> Address 2 <fill in street address, Optional> City < Fill in city name, Optional > Default values :

• Company State = Choose

• Company Country = US

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes
State < Fill in State 2

– digit code from drop down list, Optional > Zip <Fill in zip + 4, Optional>

Account or Loan number (or Social Security number for Student Loans) Only ask for the Social Security number if the Product is Student Loan.

<

fill in number, Optional >

If the consumer is concerned about providing account information : We use unique information about your account to verify that we have the right person to provide to the company and to help make sure the company reviews the correct account information. The more information you provide, the easier it will be to review and process your complaint.


### <Beginning> button <Previous> button <Next> button 38 39 Are you a Servicemember or Dependent? <Select YES or NO , “Choose” default >
{Dynamic if Answer is YES} Are you a current or former servicemember?* <Select YES or NO>
Are you a dependent/spouse of a current/former service member?* <Select YES or NO>

{Dynamic, if Answer is YES to either of the above 2 questions} What is the servicemember’s status?* <Select from drop down>

What is the servicemember’s branch of service?* <Select from drop down>

What is service member’s rank?* <Select from drop down >

{Dynamic if Answer is YES to ‘dependent/spouse’ question above } Salutation < choose one, optional> First Name* < fill in name> Middle Name < fill in name, optional> Last Name* < fill in name> Suffix < choose one, optional> Country* < choose one , United State = Default > Address 1* < fill in address> Default Values:

• Are you a Servicemember or Dependent = “Choose”

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes
Address 2 < fill in address, optional> City* < fill in city> State* < choose state code> Zip code* < fill in zip>

<Beginning> button <Previous> button <Next> button 39 40 Before I submit your case, I would like to recap your complaint and your desired resolution.
What Happened?* < See and edit what happened>

Desired Resolution?* < See and edit resolution>
For CFPB tracking purposes, can you provide me with your age? <Fill in Age, Editable>
Thank you

. Is the information provided true to the best of your knowledge and belief and do you understand that the Consumer Financial Protection Bureau cannot act as a court of law or a lawyer on your behalf, and we cannot give you legal or financial advice?
Do you agree? * < Select YES or NO> {Dynamic, if YES} <Submit Complaint> button
{Dynamic, if No} <Submit Feedback> button
{ Pop Up Message if Feedback is chosen} "Are you sure you would like to submit this complaint as feedback?
Without your acknowledgment, CFPB will not be able to communicate with you and will not be able to investigate the issue."

Agent Instructi on: Note: Submit button will SAVE the cases.

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes If it is actually a complaint, Click "OK" and confirm that the consumer agrees to the statement by Selecting "Yes" and then Click "Submit Complaint". If it is feedback (or the Consumer does not agree), Click "OK" and then Click "Submit Feedback".

<OK> button

<Beginning> button <Previous> button 40 40 {This is the view of S#40 after the < Submit Complaint > or <Submit Feedback> button is clicked}
Please proceed to next page t o review and properly save the case. <Next> button 40 41 Your feedback has been submitted. We will include the information you provided in our database for analysis and to help with supervisory and other efforts. Thanks you.

<Close> button 41 42 Your complaint has been submitted.

Your case number is ######

- ######

. {Dynamic, HL Product = Debt collection ,and original creditor (OC) case if OC case is being filed} Your other case number is ######

- ######

You can track your complaint online with a valid email address, if you provided one, by going to consumerfinance.gov

.
Click "Get Assistance..."

Then Click "Check the status of a complaint.”
We will send all updates and correspondence regarding this case to the email address provided or you can call us at 1 (855) 411

- CFPB (2372) to get updates.

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes Advise the consumer that they will need to create a password when they first attempt to log on to the consumer portal to check their status.
(If no email address was provided, go to the Contact record to update the email address.)
If consumer asks what happens next, read the following: The Consumer Financial Protection Bureau will review your complaint to make sure we send it to the right company. When we send it to them, we will ask them to respond to us and to you within 15 calendar days after CFPB sends the complaint to the company. Just be sure to keep your case number for any future contact with u s.
Thank you for calling the Consumer Financial Protection Bureau. Remember, you can also find more information at consumerfinance.gov.

< Close > button 42 43 You can mail or fax us a letter explaining your complaint or you can mail us the complaint form.
If Complaint Form - When you send in the complaint form be sure that you send in copies of all the documents you would want included with your complaint form or complaint letter. If you send in originals they will not be returned. Once your complaint is processed you cannot attach any documents.

If Fax/Mail – Be sure that you send or fax copies of all the documents you would like to be included with your complaint form or complaint letter. If you send or fax originals they will not be returned. Once your complaint is processed you cannot attach any documents.
{ Dynamic, if HL Product = Debt c ollection} For debt collection complaints, we require a signed form. I will be happy to send you our CFPB complaint form by mail to complete and return.

{NOTE: Will only appear if the HL Product is NOT Debt c ollection}
Note: If consumer wants to mail the complaint form to the CFPB, then ask consumer for their mailing address and send paper complaint form to the address they provide.

Please include your:

- Name

- Mailing Address

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes

- Phone Number

- Company Name

- Company Mailing Address

- Account Number

- Desired Resolution

- Details of any communication you have had with the company about the issue
The CFPB mailing address is: Consumer Financial Protection Bureau PO Box 4503 Iowa City, IA 52244
or Fax to (855) 237

- 2392

HT: CFPB Phone # : (855) 411

- CFPB (2372)
Once we receive and process your complaint, we will respond to you with your case number.

Set Disposition to “Publication/Forms Request” and select the correct language. Record as a Private Note the number of forms being requested by the consumer.
{ Will appear if HL Product = Mortgage} In addition to filing your complaint by mail as I just described, may I ask if you are unable to make your payments and are concerned about a possible foreclosure? < Select YES or NO>

<Go to Closing> button
<Beginning> button <Previous> button <Next> button 43 44 SCRIPT REMOVED JULY 2013 44 4/13/13 Note : Independent Foreclosure Review removed

45 Are you a veteran or member of the military?* < select Yes or No> 45

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes
46 Because of your military service you may be eligible for special benefits and personalized assistance from the Department of Veterans Affairs’ Home Loan Office. Would you like to be connected to the Department of Veterans Affairs’ Home Loan Office?
Provide the contact information for the Department of Veterans Affairs’ Home Loan Office and then cold transfer

. Thank you. I will connect you now.
The number to the Department of Veterans Affairs’ Home Loan Office is 1 (877) 827

- 3702

. <Got to Closing> button
<Beginning> button <Previous> button <Next> button 46 47 I can connect you to the Homeowner’s HOPETM Hotline to speak with a housing counselor who will assist you at no charge to you. The HOPE hotline offers personalized advice from housing counseling agencies approved by the U.S. Department of Housing and Urban Development (HUD). This national hotline is open 24 hours a day, 7 days a week.
Let me connect you with someone now. Please hold for a moment while I connect you to the Homeowner's HOPETM Hotline.
I can also provide you their contact information if we are disconnected.
The phone number is 1 (888) 995

- HOPE and the web address is www.hopenow.com

. This must be a cold transfer as the Hotline has a disclosure that must be heard by consumer.

<Caller is reluctant to be transferred to HOPE > button <Go to Closing> button
>Beginning> button <Previous> button 47 48 I'd be happy to help you with that. To best assist you, I need to ask you a few questions.

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes Would you like to continue via internet or by phone? * < Internet > button

< Phone > button
<Beginning> button <Previous> button 48 49 You may want to refer to the U.S. Department of Housing & Urban Development website at www.hud.gov or call 1 (800) 569

- 4287 to identify a HUD

- approved housing counselor in your area.
You may also find information on our website consumerfinance.gov
Are y ou comfortable with this direction?

If Yes: Cli ck on Go to Closing
IF No and the consumer asks for additional assistance with searching: Okay. I'd be happy to walk you through the tool if you'd like.

Help the consumer get to consumerfinance.gov/askcfpb and click on the appropriate Product & keyword(s). Describe what you are viewing and confirm if the caller has located the desired information.

< Go to Closing> button
<Beginning> button <Previous> button 49 50 Search the Knowledgebase using keywords. If the answer is not readily available in the Knowledgebase, refer to approved website links list.

OR
Open consumerfinance.gov in your browser

. Select Get Assistance

. Select the appropriate topic from the dropdown list.

OR

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes You may want to call the U.S. Department of Housing & Urban Development at 1 (800) 569

- 4287 or go to the website at www.hud.gov to identify a HUD

- approved housing counselor in your area.
<Go to Closing> button
<Beginning>button <Previous> button 50 51 If consumer has not already been clear about why they are reluctant to be transferred to HOPE then ask consumer why they are reluctant and select the most appropriate reason below.
__ Could not reach someone on the Homeowner’s HOPE TM 

### Hotline __ Alrea dy talked to the Homeowner’s HOPE TM 

### Hotline and that they aren’t helping __ Wants CFPB to help directly instead of the Homeowner’s Hope Hotline __ Already worked with the Homeowner’s HOPE TM 

### Hotline but HOPE cannot resolve a possible foreclosure scam to the consumer’s satisfaction ___Already gave information to the Homeowner’s HOPE TM 

### Hotline but the company I complained about is still in business __Wants CFPB to sue on their behalf __ Does not want to be transferred to Homeowner’s HOPE TM 

### Hotline (no specific reason) __ Consumer wants to file a mortgage complaint about a specific institution. 51 52 Let me connect you with someone now. Please hold for a moment while I connect you to the Homeowner's HOPETM Hotline.
I can also provide you their contact information if we are disconnected.
The phone number is 1 (888) 995

- HOPE and the web address is www.h openow.com

. This must be a cold transfer as the Hotline has a disclosure that must be heard by consumer

. <Go to Closing> button <Beginning> button <Previous> button 52 53 We are sorry to hear this. Please understand that there are a lot of people contacting the HOPE TM 

### Hotline for help right now. You may want to refer to the U.S. Department of Housing & Urban Development website at www.hud.gov or call 1 (800) 569

- 4287 to identify a HUD

- approved housing counselor in your
area.

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes

You may also want to go to the CFPB website at consumerfinance.gov for information about other resources available in your area.
If you decide to contact the HOPE TM 

### Hotline in the future, the phone number is 1 (888) 995

- HOPE and the web address is www.hopenow.com

.
<Consumer does NOT want to be connected to HOPE> button <Go to Closing> button
<Beginning> button <Previous> button 53 54 The CFPB and the U.S. Department of the Treasury have teamed up with the Homeowners’ HOPETM Hotline to connect you with housing counselors who will assist you at no charge. The housing counselors have been approved by the US Department of Housing and Urban Development and are specially trained to provide you with personal assistance with these issues. We highly recommend using this resource. Alternatively, you can follow up with your mortgage company directly if you prefer.

I can also provide you their contact information if we are disconnected.
The phone number is 1 (888) 995

- HOPE and the web address is www.hopenow.com

. This must be a cold transfer as the Hotline has a disclosure that must be heard by consumer.

< Consumer does NOT want to be connecte d to HOPE> button <Go to Closing> button
<Beginning> button <Previous> button 54 55 We are sorry to hear that. The HOPETM Hotline can only collect information on a possible scam and refer it to a centralized database where it can then be reviewed by appropriate authorities. Please know that by reporting the potential scam, you are doing a public service. The more information we can assemble on a scam operation, the greater the likelihood action can be taken by the appropriate regulator.
Would you like me to connect you with the HOPE Hotline right now?

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes I can also provide you their contact information if we are disconnected.
The phone number is 1 (888) 995

- HOPE and the web address is www.hopenow.com

.
This must be a cold transfer as the Hotline has a disclosure that must be heard by consumer.

< Consumer does NOT want to be connected to HOPE> button <Go to Closing> button
<Beginning> button <Previous> button 55 56 You may want to refer to the U.S. Department of Housing & Urban Development website at www.hud.gov or call 1 (800) 569

- 4287 to identify a HUD

- approved housing counselor in your area.
You may also want to go to the CFPB website at consumerfinance.gov for information about other resources available in your area

. HT: CFPB Phone # : 1 (855) 411

- CFPB (2372 )
Here’s the information to contact HOPE if you change your mind in the future: 1 (888) 995

- HOPE or www.hopenow.com

. <Go to Closing> button
<Beginning> button <Previous > button 56 57 We are sorry to hear that. The HOPETM Hotline can only collect information on a possible scam and refer it to a centralized database where it can then be reviewed by appropriate authorities. Please know that by reporting the potential scam and reporting its continued operation, you are doing a public service. The more information we can assemble on a scam operation, the greater the likelihood action can be taken by the appropriate regulator.
Would you like me to connect you with the HOPE Hotline right now?
I can also provide you their contact information if we are disconnected.
The phone number is 1 (888) 995

- HOPE and the web address is www.hopenow.com.
This must be a cold transfer as the Hotline has a disclosure that must be heard by co nsumer.

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes
Advise the consumer to ask for the Anti

- Scam Dedicated Team

.

< Consumer does NOT want to be connected to HOPE> button <Go to Closing> button
<Beginning> button <Previous> button 57 58 Unfortunately, we cannot assist you with bringing a civil lawsuit in your name against any entity. However, the CFPB website has information on other resources that may help you.
Also, the HOPETM Hotline has suggestions for resources that might be able to assist you with this. Would you like me to connect you to the HOPE Hotline?
I can also provide you their contact information if we are disconnected.
The phone number is 1 (888) 995

- HOPE and the web address is www.hopenow.com.
This must be a cold transfer as the Hotline has a disclosure that must be heard by consumer.

< Consumer does NOT want to be connected to HOPE> button <Go to Closing> button
<Beginning> button <Previous> button 58 59 It is very important that you have all your documents ready to upload when you go on to our website to file your complaint. The product information tab of the complaint will allow you to upload any supporting documents. Please be sure that you upload your documents prior to submitting your complaint. No documents can be attached to your complaint after you have submitted the complaint.
Offer to guide the consumer to the web form.

Please visit our website at consumerfinance.gov to submit your complaint online. HT: CFPB Phone # : 1 (855) 411

- CFPB (2372)
If you are having trouble uploading your documents, assistance in completing the complaint online may be provided by a chat agent. Just click on the link shown on the complaint form label “ Form trouble? Chat Now“ to connect to a chat agent

.

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes

<Go to Closing> button
<Beginning> button <Previous> button <Next> button 5 9 60 [standard script page] Before we close may I have your name?

Contact* < Enter contact info or Anonymous contact record, Editable > <Click if consumer does NOT want to provide contact info> button

Product* <HL Product/Sub Product, Editable> Which best describes your issue?* <Issue/Sub Issue Editable>

D isposition* <select Disposition from drop down list > Status* <Status Editable>
Agent Reminder Note s : 1. Do not provide consumers with a case number unless the consumer specifically asks for a case number. 2. Be sure to include information about a referral as a Private Note (on the Message tab). 3. Be sure to click the <Submit Inquiry> button FOLLOWED BY the <Close> button to properly save the case.
Thank you for calling the CFPB. You can also find more information at consumerfinance.gov

. <Submit Inquiry> button
{ After clicking, <Submit Inquiry> button, this ‘closing pop up is displayed.} <Close> button

<Beginning> button <Previous> button 60 Note: All fields will become “READ ONLY” after the “Submit Inquiry” button is clicked and the closing pop up is displayed.

60 [ 2015 customer Before we close may I have your name?

Contact* < Enter contact info or Anonymous contact record, Editable > Note: All fields will become “READ ONLY” after the “Submit Inquiry” button is clicked and the

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes

service survey page – temporary script language highlighted ] <Click if consumer does NOT want to provide contact info> button

Product* <HL Product/Sub Product, Editable> Which best describes your issue?* <Issue/Sub Issue Editable>

D isposition* <select Disposition from drop down list > Status* <Status Editable>
Agent Reminder Note s : 1. Do not provide consumers with a case number unless the consumer specifically asks for a case number. 2. Be sure to include information about a referral as a Private Note (on the Message tab). 3. Be sure to click the <Submit Inquiry> button FOLLOWED BY the <Close> button to properly save the case.
Are y ou willing to take a short, anonymous survey about your experience today?
{If consumer says “Yes”, say:} Thanks. Now I’m going to connect you with someone else for the survey.

Transfer call and then continue to the Submit Inquiry button

. {If consumer says “No”, say:} Thank you for calling the CFPB. You can also find more information at consumerfinance.gov

. <Submit Inquiry> button
{ After clicking, <Submit Inquiry> button, this ‘closing pop up is displayed.} <Close> button

<Beginning> button <Previous > button 60 closing pop up is displayed.

61 You must re

- select Question or Complaint before being able to continue.

< Click to re

- select Question or Complaint > button 61 62 You must re

- select whether related to a personal mortgage or on behalf of a mortgage related company

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes before being able to continue.

< Click to re

- select Personal or Company > button 62 63 Where did the transaction take place?

< Drop down or radio button selection, choose ONE > __ Online __ In person
, phone
, fax
{Dynamic depending on where transaction took place} {IF Online} What is the web site or mobile app that was used? <Text box to fill in URL or app name>
{IF In Person/Phone/Fax} Company (Sender Agent) * <fill in company name> Country (Sender Agent) * <fill in country from drop down list, ‘Choose’ Default> Address1 (Sender Agent) <fill in street address, optional> Address 2 (Sender Agent) <fill in street address, optional> City (Sender Agent) <fill in city name, optional> State (Sender Agent)* <Required if US only. code from drop down list > Zip Code (Sender Agent) <fill in zip orzip+4, optional> Telephone (Sender Agent) < fill in phone number, optional >

{ DYNAMIC, If the Primary Contact or the On Behalf of person are NOT the sender the name and address fields are presented for Agent to complete. Otherwise they are hidden.} Salutation (Sender) < choose one, optional > First Name (Sender) * < fill in name > Middle Name (Sender) < fill in name, optional> Last Name (Sender) * <fill in name> Suffix (Sender) < choose one, optional> Country(Sender)* < choose one, “Choose” default> Address 1 (Sender) <fill in address, optional> Address 2 (Sender) < fill in address, optional> City (Sender )<fill in city, optional> State (Sender) * < choose state code, REQUIRED if US = Country> Zip C ode (Sender) <fill in zip, optional >

______________________________________________________________ Can you please provide the email address and phone number given to the company for the sender ?”

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes Teleph one (Sender) <fill in phone#, optional> Email (Sender) <Fill in email address, optional>
<Beginning> button <Previous> button <Next> button 63 64 {HL Product = Money Transfer for RECEIVING INFORMATION} How was the transfer received?

< Drop down or radio button selection, choose ONE > ___In person or at home? ___Deposited or credited to an account?
Company (Receiving Agent)* <Fill in name> Country (Receiving Agent) * <choose one, “Choose” default> Address 1 (Receiving Agent) < fill in address, optional> Address 2 (Receiving Agent) < fill in address, optional> City (Receiving Agent) <fill in city, optional> State (Receiving Agent)* < choose state code, REQUIRED if US = Country> Zip C ode (Receiving Agent) < fill in zip, optional>

{If DEPOSITED OR CREDITED} Website or Mobile app name (Receiving Agent)? <Text box to fill in URL or app name>
Can you provide the account number? <Fill in account number>

If the consumer is concerned about providing account information : We use unique information about the account to verify that we have the right person to provide to the company and to help make sure the company reviews the correct account information. The more information you provide, the easier it will be to review and process the
co mplaint.


### { DYNAMIC, If the Primary Contact or the On Behalf of person are NOT the recipient the name and address fields are presented for Agent to complete. Otherwise they are hidden.} Salutation (Recipient) < choose one, optional> First Name (Recipient) * < fill in name> Middle Name (Recipient) < fill in name, optional> Last Name (Recipient) * <fill in name> Suffix (Recipient) < choose one, optional> Country (Recipient)* <choose one>

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes
Address 1 (Recipient) <fill in address, optional> Address 2 (Recipient) <fill in address, optional> City (Recipient) <fill in city, optional> State (Recipient)* <choose state code, REQUIRED if US = Country> Zip C ode (Recipient) < fill in zip, optional>

Can you please provide the email address and phone number given to the company for the recipient ? Telephone (Recipient) < fill in phone#, optional> Email (Recipient) < Fill in email address, optional>
<Beginning> button <Previous> button <Next> button 64 65 { DYNAMIC, If High Level Product = Debt collection}
Are you filing this complaint only on behalf of yourself? <select Yes or NO>

{

DYNAMIC, If answer to above question is “NO””
We are only able to take Debt collection complaints by phone if you are filing individually. I’d be happy to have a debt collection complaint form sent to you by mail. You’ll need to make sure that both you and the other party sign the form before returning it to us.
<Go to Closing> button

<Beginning> button <Previous> button <Next> button 65 66 {If High Level Product = Debt c ollection}
{If sub Product = Payday loan} Where did you get the payday loan? <Select “In person / at a store” or “Online”> If consumers indicate that they applied online but picked up their loan in person, select “In person / at a

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes

store”
{Dynamic, if “In person / at a store” selected } In which state is the store located? <Select US state, dropdown list> If the consumer asks why we need this information, say : ”This is important because different states have different laws for payday loans.”
{ Dynamic , if “Online” selected} What is the website you used to apply for the payday loan? <Fill in web URL>
What company is contacting you about this debt?* <Fill in company name>

Enter the company name provided by the consumer. If there is an exact match, you may select from the list. Otherwise, enter the full name as provided by the consumer.

If caller does not know name of debt collection company, click on the 'Unknown Company' button 

### <Company Unknown button> If caller says company is the Department of Education or Federal Student Aid, click on the 'Department of Education' button. 

### <Dept. of Education> button
{Dynamic, appears if the company is unknown} Since you don’t know the name of the company we will be unable to send this complaint to a company. All complaints will be used to help the CFPB understand consumers’ experiences and monitor providers of financial products and services. If you are able to identify the company that is contacting you in the next 30 days, you can provide that information by calling us.

{Dynamic, appears if company is NOT “unknown”} Do you have an address for this company? Address 1 <fill in address, optional> Address 2 <fill in address, optional> City <fill in city, optional> State <fill in state from drop down menu, optional> ZIP code <fill in zip code+4, optional> Country <fill in country from drop down menu, United States if default)

{ Dynamic, appears only if the Issue =C ommunication s tactics and the sub

- issue is the 1 st



### , 2 nd 

### or 5 th 

### in the sub issue list }

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes What phone number are they calling? <fill in caller’s phone # called by debt collector> This is the caller’s phone number that the debt collector is dialing.

Can you provide a phone number the company is calling you from? <fill in phone number, optional> {Dynamic, appears if one phone number is provided} Is there a second phone number that they’ve called you from? <fill in phone number, optional> This phone number is the number that appears in the caller ID on a phone or may have been provided by the company.
Do you know the name or ID # of the debt collection company’s representative who you’ve spoken to? <fill in name, optional>
Do you have an account number used by the debt collector when they contact you? <fill in account number, optional>
May I have the last 4 digits of your Social Security Number? <Enter SSN(4)>
Do you know where this debt came from? <Same company>button <Different company> button <I don’t know> button If caller is confused by the above question, say “ We want to know if the people contacting you were hired by another company to collect their debts. If your debt has come from a different company, we'll give you the option to file two complaints about your issue: one complaint with the debt collector and a second complaint with the company that owns the debt. If you don't know where the debt came from, you should sel ect the "I don't know" option.”
<Beginning> button <Previous> button <Next> button 66

- routing 67 {If High Level Product = Debt c ollection and “do you know where debt came from?” = Different Company (in S#66)}

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes

What is the name of the original creditor company?* <Fill in company name>

Enter the company name provided by the consumer. If there is an exact match, you may select from the list. Otherwise, enter the full name as provided by the consumer.

If caller does not know name of debt collection company, click on the 'Unknown Company' button 

### <Company Unknown button> If caller says company is the Department of Education or Federal Student Aid, click on the 'Department of Education' button. 

### < Dept of ED> button

{Dynamic, appears if the company is unknown} Since you don’t know the name of the company we will use your complaint to help the CFPB understand consumers’ experiences and monitor providers of financial products and services. If you are able to identify the creditor in next 30 days, you can provide that information by calling us.

Do you want to submit a complaint against this company too ?* <Select YES or NO> If the caller is confused by the above question: “ The original creditor company name will be sent to the company contacting you about your debt to help their investigation. If you answer “Yes” to this question, CFPB will also send the complaint to the original creditor you provided.”
{Dynamic, appears on ly if the caller want to submit a complaint against the original creditor}

{Dynamic, appears if company is NOT “unknown”} Do you have an address for this company? Address 1 <fill in address, optional> Address 2 <fill in address, optional> City <fill in city, optional> State <fill in state from drop down menu, optional> ZIP code <fill in zip code+4, optional> Country <fill in country from drop down menu, United States if default)

If they are calling you, can you provide a phone number the company is calling you from? <fill in phone number, optional> {Dynamic, appears if one phone number is provided} Is there a second phone number that they’ve called you from? <fill in phone number, optional> This phone number is the number that appears in the caller ID on a phone or may have been provided by

# Agent Scripts March 1, 2015 V5.01

Script # Script Text Comments/Notes the company.
Do you know the name or ID # of the original creditor company’s representative who you’ve spoken to? <fill in name, optional>
Do you have an account number assigned by the original creditor ? <fill in account number, optional>

<Beginning> button <Previous> button <Next> button 67 68 {If HL Product = Credit r eporting & caller wants to file a complaint (S#3 response = Complaint)}

Unfortunately we cannot take your complaint by phone at this time. In order to work on your credit reporting complaint, we need your permission to have access to your credit report. We’ll only use your credit report to work on your complaint, but we can’t get started until we have your permission to get it.
Do you have access to the I nternet? <click on YES or NO button>

{Dynamic } If YES: You can complete the form on our website consumerfinance.gov . Once it is submitted, we will process the complaint

If NO: I can mail you a complaint form and a consent form.

Please fill out the forms and send them back to us via fax at (855) 237

- 2392 or mail it to us at: Consumer Financial Protection Bureau P.O. Box 4503 Iowa City, Iowa 52244

< Beginning> button <Previous> button
<Go to Closing> button 68