Consumer Response Intake Form

ICR 201106-1505-005

OMB: 1505-0241

Federal Form Document

IC Document Collections
ICR Details
1505-0241 201106-1505-005
Historical Active
TREAS/DO
Consumer Response Intake Form
New collection (Request for a new OMB Control Number)   No
Regular
Approved with change 11/18/2011
Retrieve Notice of Action (NOA) 06/30/2011
Collection was modified to address use of information collected and whistleblower references provided.
  Inventory as of this Action Requested Previously Approved
11/30/2014 36 Months From Approved
3,000,000 0 0
387,500 0 0
0 0 0

The Intake Form is designed to aid consumers in the submission of complaints, questions, and comments and to help the CFPB fulfill the aforementioned statutory requirements. Consumers (hereinafter "respondents") will be able to complete and submit information through the Intake Form electronically on the CFPB's website. Alternatively, respondents may request that the CFPB email a fillable PDF version or, by telephone, request a "paper" copy of the Intake Form, and then email, mail, or fax it to the CFPB. The questions within the Intake Form prompt respondents for a description of, and key facts about, the complaint at issue, the desired resolution, contact and account information, information about the institution they are filing a complaint against, and any previous action taken to attempt to resolve the complaint. Responses to these questions will help document the substance of the complaint, question, or comment; information necessary to identify the subject incident, consumer, and institution; and contact information needed to follow-up on the complaint, question, or comment.

PL: Pub.L. 111 - 203 1013 Name of Law: Dodd–Frank Wall Street Reform and Consumer Protection Act
  
PL: Pub.L. 111 - 203 1013 Name of Law: Dodd–Frank Wall Street Reform and Consumer Protection Act

Not associated with rulemaking

  76 FR 13018 03/09/2011
76 FR 38458 06/30/2011
Yes

2
IC Title Form No. Form Name
Consumer Response Intake Form (Paper/Telephone) TD F 104.3 Consumer Response Intake Form
Consumer Response Intake Form (Web)

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 3,000,000 0 3,000,000 0 0 0
Annual Time Burden (Hours) 387,500 0 387,500 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
This is a new collection.

No
No
No
Yes
No
Uncollected
Lea Mosena 202 435-7152

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
06/30/2011


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