Form FR 1379c FR 1379c Federal Reserve Consumer Help - Online Complaint Form

FR 1379c - OMB No. 7100-0135
Approval expires May 31, 2011
Please print clearly below.
Mail or fax this completed form to:
Federal Reserve Consumer Help
PO Box 1200, Minneapolis, MN 55480
Fax: 877-888-2520

CONSUMER COMPLAINT FORM

Questions? Call us at 888-851-1920
YOUR INFORMATION

Name:
Please provide either a mail address, e-mail address, or phone number so that we can contact you.
Address:

City

E-mail:
Contact Preference:

State

Phone:
Mail

E-mail

Zip Code

Country

Alternate Phone:

Phone
INSTITUTION INFORMATION

Institution Name:
Please provide as much information as possible about the bank or financial institution.
Account / Product Type:
Address:
E-mail:

City

State

Zip Code

Country

Phone:

Please provide contact or location information about the bank or financial institution.
Do not include any personal information such as account numbers or Social Security numbers.

COMPLAINT
Provide a description of the complaint including the names of those you dealt with at the bank, along with the dates.
Tell us what happened. The more information we have about the problem, the faster we can investigate and respond.
Do not include any personal information such as account numbers or Social Security numbers.

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FR 1379c
YOUR
INFORMATION
COMPLAINT

How can your complaint be satisfactorily addressed?

How did you learn about Federal Reserve Consumer Help? Check all that apply.
Federal Reserve website/other website/search engine (specify: ________________________________________________)
Bank/financial services company/consumer brochure (specify: _________________________________________________)
Referral from another federal/state agency (specify: __________________________________________________________)
Friend/relative/newspaper/magazine article/other (specify: ___________________________________________________)
Privacy Act Statement
The information that you provide will permit the Federal Reserve to respond to consumer complaints and inquiries regarding practices by banks and other
financial institutions supervised by the Board of Governors of the Federal Reserve System. The information may be disclosed:
• to a Federal Reserve-regulated entity that is the subject of a complaint or inquiry;
• to third parties to the extent necessary to obtain information that is relevant to the resolution of a complaint or inquiry;
• for enforcement, statutory, and regulatory purposes;
• to another agency or Federal Reserve Bank;
• to a member of Congress; to the Department of Justice, a court, an adjudicative body or administrative tribunal, or a party in litigation;
• to contractors, agents, and others; and
• where security or confidentiality has been compromised.
This collection of information is authorized by 12 U.S.C. §§ 248 and 1844, 15 U.S.C. § 57a(f ), and other consumer protection laws.
You are not required to file a complaint or inquiry and you may withdraw your complaint or inquiry at any time.
However, if you do so, the Federal Reserve may not be able to investigate your complaint or inquiry.

Paperwork Reduction Act Notice
This form is authorized by law (15 U.S.C. §57(a)(f )(1)) and is voluntary.
Public reporting burden for this information collection is estimated to average ten minutes per response. Send comments regarding this burden estimate
or any other aspect of this information collection, including suggestions for reducing this burden, to Secretary, Board of Governors of the Federal Reserve System,
20th and C Streets, N.W., Washington, DC 20551; and to the Office of Management and Budget, Paperwork Reduction Project (7100-0181), Washington, DC 20503.

Signature:

Date:
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