Customer Complaint Form

CUSTOMER COMPLAINT FORM

Please fill in this form completely. Mail or fax this completed complaint form 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)

Once we have received your completed form, you will receive a acknowledgment letter containing your assigned case number. Please utilize your case number for future contact with our office.

Helpful Hints:

Check to make sure your financial institution is a National Bank. If you do not know the name of your bank, check your bank or credit card statement. The bank’s name will be indicated on the statement.

Have you tried to resolve your complaint with your financial institution? If not, please contact your financial institution first to allow them the opportunity to resolve your issue.

Please note that if your complaint involves more than one financial institution, you will need to submit a separate complaint form for each institution involved. You will receive separate case numbers for each institution.

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

Your Information

The Account Owner/Holder should complete this section.

* - Indicates Required Fields

*First Name:	Middle Name:
*Last Name:
*Street Address:
*City:		*State:	*Zip: -
*Phone:
Email:
What is the best way to contact you? Phone Mail Email
What is the best time to contact you? Morning Afternoon Evening

Representative Contact Information

If you have an attorney or other legal representative you want us to deal with directly, please provide their information below. Your submission of this portion of the form authorizes your financial institution and our office to release information to your attorney or other legal representative if requested. Please check the following to indicate the type of relationship:

Attorney Legal Representative

Please indicate the type of authorization you have granted to your attorney or other legal representative:

Power of Attorney Letters Testamentary Court Appointed Executor or Administrator Other

If you are not sure of the type of legal authorization granted, please check your legal documents or consult with your attorney or other legal representative.

Name of Representative:

*First Name:	Middle Name:
*Last Name:
*Street Address:
*City:		*State:	*Zip: -
*Phone:
Email:
What is the best way to contact your representative? Phone Mail Email
What is the best time to contact your representative? Morning Afternoon Evening

Financial Institution or Company Information that is subject of the complaint

Helpful Hint: If you do not know the name of your bank, check your bank or credit card statement. The bank’s name will be indicated on the statement.

*Name of Financial Institution or Company:
Street Address:
*City:			*State:	Zip: -
Phone:
*Type of Account(s) (Check all that apply): Deposit Account (Checking, Savings): Credit Card Insurance Mortgage
Loan Product (Consumer, Mortgage, Home Equity): Asset Management (Trust Accounts):
Consumer Leasing: Non-Deposit Account (Investments): Insurance: Other:
Have you tried to resolve your complaint with your financial institution or company? Yes No
If Yes, When?	How? Phone Mail In Person Other
Contact Name:		Title:
Has the bank responded to you? Yes No
If Yes, When?	How? Phone Mail In Person Other

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). Be as brief and complete as possible to make the explanation clear. Do not include Personal or Confidential information such as your Social Security, Credit Card, or Bank Account Numbers.

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

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 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 this form is true and correct to the best of my knowledge.

I Certify I Do Not Certify

Date:____________________

Signature:_____________________________________________

We will mail you a written acknowledgment within five (5) business days of receipt of your completed complaint form containing your assigned case number. Please utilize your case number for future contact with our office.. If you have any questions regarding this case, please call 1-800-613-6743.

If a valid OMB Control Number does not appear on this form, you are not required to complete this form.

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