Consumer Response Intake Form

Forms and Documents

Document Name	Status
Form TD F 104.3 Consumer Response Intake Form (Paper/Telephone) Form	New
Supporting Statement for Standard Intake Form PRA 11-14-2011.doc Supporting Statement A	2011-11-16

IC Document Collections

IC ID	Document Title	Status
198358	Consumer Response Intake Form (Paper/Telephone) Form	New
198357	Consumer Response Intake Form (Web) Other-Screen shot	New

ICR Details

OMB Control No: 3170-0011	ICR Reference No: 201111-3170-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: CFPB	Agency Tracking No:
Title: Consumer Response Intake Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/21/2011
	Date Received in OIRA: 11/21/2011
Terms of Clearance: Collection was modified to address use of information collected and whistleblower references provided.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2014	36 Months From Approved
Responses	3,000,000	0	0
Time Burden (Hours)	387,500	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: 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.

---

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

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

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 13018	03/09/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 38458	06/30/2011
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 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)

---

ICR Summary of Burden

	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

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection.

---

Annual Cost to Federal Government:

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Yes

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 06/30/2011

---