Screening/Participation Instruments

OMB No. 1505-0233

Confidentiality Statement and Consent Form: Part I

The Kleimann Communication Group is working on a project for the Consumer Financial Protection Bureau (CFPB). We are not employees of the CFPB.

This project will collect information about mortgage loan disclosures with the aim of improving consumer experience and understanding. We want to assure you that, to the extent permitted by law, we will maintain the confidentiality of your identity in all instances and, unless your express written consent waiving your right to confidentiality provided in Part II of this Form, we will maintain the confidentiality of your participation and responses in this project.

This document is meant to inform you of your rights as you talk with us today. By signing below, you are indicating that you understand that:

• Your participation is completely voluntary. You do not have to answer any question you do not want to and you may stop participating at any time.

• Your identity will be kept confidential to the extent permitted by law. We will report demographic information about participants in only a summary format.

• Unless your written consent is provided in Part II of this Form, your responses will be kept confidential to the extent permitted by law. If your express written consent is provided in Part II of this Form, we may videotape and/or audiotape our session with you. Such recordings will be used to review your comments and interactions with the disclosures and accurately describe them.

• The interview will take no more than 90 minutes to complete.

If you agree to help us, please print your name, then sign and date this form below.

We thank you for your participation in this important project, which will serve to improve the communication of lender-required disclosures of important information to American families applying for a mortgage loan.

I have read this document in full and understand my rights related to my participation on this project.

Name (please print):

Signature:

Today’s Date:

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the collection of information displays a valid control number assigned by the Office of Management and Budget (OMB). The OMB control number for this collection is 1505-0233, and expires 11/30/2011.

OMB No. 1505-0233

Video/Audio Consent Form: Part II

The Consumer Financial Protection Bureau (CFPB) is interested in making video and audio recordings of this process in an effort to share the results of this study with the CFPB mortgage loan disclosure development team, as well as potentially others outside of the CFPB, with the purpose of improving consumer experience and understanding.

If you consent to a video recording of your interview, clips of your interview may be included in a video-tape of the process for internal CFPB use and may be included in a video montage, or collection, showing clips of individual interviews that may be shared outside of the CFPB. Besides your image, at no time will your name or other identifying information be provided with any video of you.

If you consent to an audio recording of your interview, sound bites of your interview may be included in an audio-recording of the process for internal CFPB use. At no time will your name or other identifying information be provided with any audio recording of you.

If you agree to a recording of your interview, please check each item you agree to:

• I agree to a video recording of my interview.

• I agree to an audio recording of my interview.

By signing below, you are indicating that you understand that:

• No personal information, besides your image if you agree to a video recording of your interview, would be included about you. If any name is provided by the CFPB, it will be a pseudonym.

• If you do not give permission for your image to be used, it will not be used.

• Giving or not giving permission will not exclude you from participating in the session.

• No additional compensation is offered beyond the stipend you will be paid today.

If you agree to let us record your interview for the purposes noted above, whether by video and/or audio recording, please print your name, then sign and date this form below.

We thank you for your participation in this important project, which will serve to improve the communication of lender-required disclosures of important information to American families applying for a mortgage loan.

I have read this document in full and consent to waive my right to have the confidentiality of my participation in this project maintained as specified above.

Name (please print):

Signature:

Today’s Date:

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the collection of information displays a valid control number assigned by the Office of Management and Budget (OMB). The OMB control number for this collection is 1505–0233, and expires 11/30/2011.

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