Form FDIC-6422/04 Customer Assistance Form

PRIVACY ACT STATEMENT

Collection of this information is authorized by section 9 of the Federal Deposit Insurance Act (12 U.S.C. § 1819) and section 202(f) of Title II of the Federal Trade Improvement Act (15 U.S.C. § 57a(f)). The information requested on this form will be used to investigate and respond to your complaint or inquiry, and may be disclosed outside the FDIC in accordance with the "routine uses of records" listed in the FDIC's Consumer Complaint and Inquiry System of Records, # 30-64-0005. Those uses include disclosure to the institution which is the subject of the complaint or inquiry and to any third party sources, when necessary to investigate or resolve the complaint or inquiry; to the Federal or State supervisory authority that has direct supervision over the financial institution that is the subject of the complaint or inquiry; to appropriate Federal, state, or local authorities for enforcement if a violation of possible violation of civil or criminal law is discovered; and to a congressional office in response to any inquiry made at your request. Completion of this form is voluntary, but failure to provide requested information may delay or preclude investigation of your complaint or inquiry.

PAPERWORK REDUCTION ACT NOTICE

Public reporting burden for this collection of information is estimated to average .25 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and review the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17^th Street, N.W., Washington, D.C. 20429, and the Office of Management and Budget, Paperwork Reduction Project (3064-0134), Washington, D.C. 20503. An agency may not conduct or sponsor, and a person is not required to respond to, a collection unless it displays a currently valid OMB control number.

Page down to access form FDIC 6422/04

OMB NUMBER: 3064-0134

EXPIRATION DATE: 4/30/2009

Federal Deposit Insurance Corporation CUSTOMER ASSISTANCE FORM
INSTRUCTIONS: Please print or type. If you are unable to resolve a complaint directly with your financial institution, you may file a formal complaint with the FDIC by writing a letter or completing this form, and mailing it to the FDIC Regional Office for the state in which the financial institution is headquartered.
SECTION I - CONSUMER INFORMATION
NAME (Last, First, MI)		DAYTIME TELEPHONE NUMBER
     		(     )      -     
ADDRESS
     
CITY	STATE	ZIP CODE
     	     	     
SECTION II - FINANCIAL INSTITUTION INFORMATION
NAME OF INSTITUTION
     
ADDRESS
     
CITY	STATE	ZIP CODE
     	     	     
SECTION II - NATURE OF PROBLEM (Describe the nature of your complaint, the events in the order in which they occurred, including specific dates, if possible, and the product or service which is the subject of the complaint. Attach copies, not originals, of all documents that relate to your complaint. In addition, tell what resolution you are seeking.)
DESCRIPTION

Click here to type text. If additional space is needed, use the TAB key to insert another row. Otherwise, move the mouse to the next field.)

San Francisco Dallas Kansas City Chicago Memphis Atlanta New York Boston Division of Supervision and Consumer Protection Regional Offices
Atlanta Ten Tenth Street, NE Suite 800 Atlanta, GA 30309-3415 (404) 817-1300 States Covered: Alabama, Florida, Georgia, North Carolina, South Carolina, Virginia, West Virginia Dallas 910 Pacific Avenue Suite 1900 Dallas, TX 75201 (214) 754-0098 States Covered: Colorado, New Mexico, Oklahoma, Texas	Boston 15 Braintree Hill Office Park Braintree, MA 02184 (781) 794-5500 States Covered: Connecticut, Maine, Massachusetts, New Hampshire Rhode Island, Vermont Kansas City 2345 Grand Avenue Suite 1500 Kansas City, MO 64108 (816) 234-8000 States Covered: Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota		Chicago 500 West Monroe Suite 3200 Chicago, IL 60661 (312) 382-7500 States Covered: Illinois, Indiana, Kentucky, Michigan, Ohio, Wisconsin Memphis 5100 Poplar Avenue Suite 1900 Memphis, TN 38137 901-685-1603 States Covered: Arkansas, Louisiana, Mississippi, Tennessee
New York 20 Exchange Place 4th Floor New York, NY 10005 (917) 320-2750 States Covered: Delaware, District of Columbia, Maryland, New Jersey, New York, Pennsylvania, Puerto Rico, Virgin Island		San Francisco 25 Jessie Street at Ecker Street Suite 2300 San Francisco, CA 94105 (415) 546-0160 States Covered: Alaska, American Samoa, Arizona, California, Federated States of Micronesia, Guam, Hawaii, Idaho, Montana, Nevada, Oregon, Utah, Washington, Wyoming
FDIC Call Center: 1-800-934-3342