Form OTS Form 1723 OTS Form 1723 Consumer Complaint Form

OMB Control No.:
Expiration Date:
	Office of Thrift Supervision CONSUMER COMPLAINT FORM
Public reporting burden for this collection of information is estimated to average 3 to 15 minutes to complete the form and provide a narrative. Send comments regarding this burden estimate or other aspects of this collection of information, including suggestions for reducing the burden to: the Office of Thrift Supervision, Compliance and Consumer Protection Division, 1700 G Street, N.W. Washington, DC 20552.
How to Resolve a Consumer Complaint: If you have a complaint about a thrift institution or savings association, the Office of Thrift Supervision (OTS) may be able to help. The OTS is an office of the Department of the Treasury that regulates and supervises the nation’s thrift industry. The OTS’s mission is to ensure the safety and soundness of thrift institutions and their compliance with consumer protection laws. The OTS also supports the important role thrift institutions play as home mortgage lenders and providers of other forms of community credit and financial services. Additionally, the OTS oversees the activities and operations of thrift operating subsidiaries and holding companies that own or control thrift institutions. Please Note: We cannot act as a court of law or as a lawyer on your behalf. We cannot give you legal advice. We cannot become involved in complaints that are in litigation or have been litigated. Instructions for Submitting a Consumer Complaint Form: To submit a complaint, you may write a letter explaining your issues or complete the form. Please type or print your request and mail or fax your complaint to: Office of Thrift Supervision Consumer Affairs Division 1700 G Street, N.W. Washington, DC 20552 202-906-7342 (Fax) 1-800-842-6929 (Phone)
Your Information:
Salutation: Mr. Ms. Mrs. Other:      
Last Name:      		First Name:      			Middle Initial:  
Street Address:      
City:      			State:      			Zip Code:      -    
Daytime Phone: (   )    -    			Email:      
What is the best way to contact you? Phone Mail Email
What is the best time to contact you by phone? Morning Afternoon

OTS Form 1723

August 2008

Additional Contact Information:
If you have an attorney or other representative you want us to deal with directly, please provide your representative's information below. Your signature on this form authorizes your savings association and our office to release information to your representative.
Name of Representative:      			Relationship:      
Street Address:      
City:      	State:      	Zip Code:      -    		Phone: (   )    -    

Information about the Savings Association, or its operating subsidiary or holding company, that is the subject of the complaint:
Name of Savings Association:      
Street Address:      
City:      		State:      		Zip Code:      -    	Phone: (   )    -    
Type of Account:      
Have you tried to resolve your complaint with your savings association? YES NO
If Yes, When?   /  /    	How? Phone Mail In Person Other:      
Savings Association Contact Name:      			Title:      
Have you contacted or filed a complaint with another government agency? YES NO
If Yes, Agency Name?      
Complaint Information:
Describe events in the order in which they occurred, including any names, phone numbers, and a full description of the problem with the amount(s) and date(s) of any transaction(s). You should also include any response from the savings association. Be as brief and complete as possible to make the explanation clear. Use separate sheets of paper if you need more space. Please include copies of documents related to your complaint such as contracts, monthly statements, receipts and correspondence with the bank. Do not send original documents.
     

OTS Form 1723

August 2008

Please be advised that the issues described in this complaint will be shared with the savings association in question for its response.
Desired Resolution:
Describe how you would like this matter resolved.      
I certify that the information provided on, or with, this form is true and correct to the best of my knowledge.
			  /  /    
	Signature		Date
OTS Form 1723 April 2008
We will mail you a written acknowledgment within five (5) business days of receipt of your completed complaint form. If you have any questions regarding your complaint case, please call 1-800-842-6929.
PRIVACY ACT STATEMENT The solicitation and collection of this information is authorized by 15 U.S.C. 57a(f) and 12 U.S.C. 1, et. seq. The information is solicited to provide the Office of Thrift Supervision (OTS) with information that is necessary and useful in reviewing requests received from individual consumers for assistance in their interactions with savings associations and their affiliates. The provision of information is voluntary. Without such information, however, the ability of OTS to complete a review and provide assistance may be limited or hindered. It is intended that the information you provide will be used within OTS and provided to officials of the savings association or affiliate that is the subject of the complaint or inquiry. Additional disclosures of such information may be made to: appropriate law enforcement agencies or authorities in connection with investigation and/or prosecution of alleged civil, criminal and administrative violations; to a Congressional office in response to an inquiry made at the request of the individual to whom the record pertains; to other Federal and nonfederal governmental supervisory or regulatory authorities when the subject matter is within such other agency’s jurisdiction; in a civil, criminal or administrative proceeding before a court, magistrate, administrative or arbitration tribunal, in the course of pre-trial discovery, motions, trial, appellate review or in settlement negotiations when OTS, the Director of OTS, an OTS employee, the Department of Treasury, the Secretary of Treasury, or the United States is a party or has an interest in or is likely to be affected by such proceeding and an OTS attorney determines that the information is arguably relevant to the proceeding; to the Department of Justice, private counsel or an insurance carrier for the purpose of defending an action or seeking legal advice to assure that the agency and its employees receive appropriate representation in legal proceedings.