Customer Complaint Form

O

OMB Control No. 1557-0232
Expiration Date: 12/31/2008

Comptroller of the Currency
Administrator of National Banks

CUSTOMER COMPLAINT FORM
Please fill in this form completely, including your signature at the end of the form. If a valid OMB
Control Number does not appear on this form, you are not required to complete this form. The Office of
the Comptroller of the Currency (OCC) will only act on complaints that are signed by the
complainant(s), legal guardian, attorney of complainant(s) along with their client’s authorization, or
holder of power of attorney.
Mail or fax this completed complaint form with any attachments to:
Office of the Comptroller of the Currency
Customer Assistance Group
1301 McKinney Street, Suite 3450
Houston, TX 77010-9050
1-713-336-4301 (Fax)

Please Note:
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•
•

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

Y OUR I NFORMATION
Salutation: Mr.
First Name:

Ms.

Mrs.

Other:
Middle Initial:

Last Name:

Street Address:
City:

State:

Home Phone:

Work Phone:

Email:
What is the best way to contact you? Phone

Mail

What is the best time to contact you? Morning

Email

Afternoon

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Evening

Zip:

A DDITIONAL C ONTACT I NFORMATION
If you want us to communicate with someone else, such as a family member, attorney, or other person
representing you about this complaint, then please provide your representative’s information below. If
you list someone else and sign this form, you allow us to communicate with and provide relevant
information that is about you to that person.
Name of Representative:
Relationship:
Street Address:
City:

State:

Zip:

Phone:

F INANCIAL I NSTITUTION OR C OMPANY I NFORMATION THAT IS SUBJECT OF THE
COMPLAINT
Name of Financial Institution or Company:
Street Address:
City:

State:

Zip:

Phone:
Type of Account(s): Credit Card:

Checking

Mortgage

Other:

Have you tried to resolve your complaint with your financial institution or company? Yes
If Yes, When?
Contact Name:

How? Phone

Mail

In Person

No

Other

Title:

Have you filed a complaint or contacted another government agency? Yes

No

If Yes, Agency Name?

C OMPLAINT I NFORMATION
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 financial institution or company.

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Be as brief and complete as possible to make the explanation clear. Use separate sheet(s) 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.

Please be advised that the issues described in this complaint will be shared with the financial institution
or company in question for their response.

D ESIRED R ESOLUTION
What action by the financial institution or company would resolve this matter to your satisfaction?

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P RIVACY A CT S TATEMENT
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 the Comptroller of the Currency (OCC) with
data that is necessary and useful in reviewing requests received from individuals for assistance in their
interactions with national banks. The provision of requested information is voluntary. However, without
such information, the ability to complete a review or to provide requested assistance may be hindered.
It is intended that the information obtained through this solicitation will be used within the OCC and
provided to the national bank that is the subject of the complaint or inquiry. Additional disclosures of
such information may be made to: (1) other third parties when required or authorized by statute or when
necessary in order to obtain additional information relating to the complaint or inquiry; (2) other
governmental, self-regulatory, or professional organizations having: (a) jurisdiction over the subject
matter of the complaint or inquiry; (b) jurisdiction over the entity that is the subject of the complaint or
inquiry; or (c) whenever such information is relevant to a known or suspected violation of law or
licensing standard for which another organization has jurisdiction; (3) the Department of Justice, a
court, an adjudicative body, a party in litigation, or a witness when relevant and necessary to a legal or
administrative proceeding; (4) a Congressional office when the information is relevant to an inquiry
initiated on behalf of its provider; (5) Other governmental or tribal organizations with which an individual
has communicated regarding a complaint or inquiry about an OCC-regulated entity; (6) OCC
contractors or agents when access to such information is necessary; and (7) other third parties when
required or authorized by statute.
I certify that the information provided on, or with, this form is true and correct to the best of my
knowledge.
Signature:

Date: ___

_______

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 this case, please call 1-800-613-6743.

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