Form TD F 104.3 TD F 104.3 Consumer Response Intake Form

Consumer Assistance Form
You should fill out this form if you have a complaint, comment, or question about a financial institution, financial
product, or financial service, or the Consumer Financial Protection Bureau (CFPB). The more information you
provide, the better we will be able to understand your issue. Please fill in this form completely and mail or fax to:
The Consumer Financial Protection Bureau
[Address]
Washington, DC [Zip Code]
FAX: [Fax Number]
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Keep a copy of your completed form for your records. Once we receive your form, we will provide you with a
case number. Keep this case number for future contact with the CFPB.
For most complaints, the CFPB forwards some information from this form to the company you identify. You
can submit information anonymously, but we may not be able to take action. All complaints will be used to
help the CFPB understand consumers’ experiences and monitor providers of financial products and services.
If you are filing a complaint on behalf of someone else, we may need this person’s signed, written permission
to take action. Except where noted, all items refer to the consumer with the issue.
Review the Privacy Act Statement found on the last page of this form.
We cannot act as a court of law or as a lawyer on your behalf and cannot give you legal or financial advice.

1) I have a:* Check only one.
Complaint about something that
happened to me involving a
financial institution, product, or
service
2) What happened?*
Describe your complaint.
Include facts about what happened
and any steps you have taken to
resolve the issue.

Alert about a financial
institution, product, service, or
practice that I think the CFPB
should look into
Share your story.*
Tell us about what happened.

3) Is this about something that happened to you / someone you know?*

Comment or Question about a
financial institution, product,
service, or practice or the
CFPB
Tell us your question or comment.*
Complete Item 2 and skip to Item 19

Yes

No

4) Is this about something you observed while working for a financial institution or financial service provider?*
Employees of a bank or other consumer financial service provider may be entitled to
No
Yes
certain protections. For more information visit www.whistleblowers.gov.
If yes, skip to Item 11
* Answers to these questions are necessary for the CFPB to take action

5) This is about:*
Check only one.
Credit Products
Deposit Products
Credit Card
Payday Loan
Cash Advance Loan
Student Loan - Federal
Student Loan - Private
Tax Refund Anticipation Loan
Car / Auto Loan
Car Title Loan
Mortgage/Home Loan
Mortgage Loan—Purchase
Mortgage Loan—Refinance
Home Equity Loan / Line of Credit
Reverse Mortgage
Second Mortgage
Other: ____________________

Financial Advisory Service

Checking Account
Savings Account
Certificate of Deposit (CD)
Money Market Account
Deposit Insurance

Methods of Payment
ACH Transfer

Credit Counseling
Debt Management/Settlement
Investment Advice (not broker-dealer)
Financial Planner

Property Development
Settlement Service
Subdivision/Condo Development

ATM/Debit Card
Check Cashing
Checks
Currency Exchange
Gift Card
Money Order
Money Transmission or Remittance
Prepaid Card / Stored Value Card

Other
Debt Collection
Consumer Leasing
Identity Theft
Individual Retirement Account (IRA)
Pawn Broker
Safe Deposit Box

Credit Reporting
Credit Report / Credit Score
Information Given to Credit
Reporting Agency

6) The issue with this product or service checked above is:*____________________________________________
7) Do you believe the issue involves discrimination?

Yes

No

If yes, check the basis for the discrimination: Check all that apply.
Exercise of Rights Under Consumer Credit Protection Act
National Origin
Marital Status
Age
Receipt of Public Assistance
Religion
Sex
Race or Color
Describe any discrimination in the description area on page 1

8) When did this happen? ____ / ____ / ________

Don’t Know

9) Estimate the total dollar value of your loss based on what you know right now.

$ ____________

10) What do you think would be a fair resolution of this issue?* _______________________________________
_________________________________________________________________________________________
11) I want to submit anonymously. I understand the CFPB may not be able to respond or take action.*
If yes, skip to Item 15
Yes

No

12) I do not want the CFPB to send information about me to the company. I understand that the
CFPB may not be able to take action.*

No

13) Do you have a loan or account number for this product?* If yes, provide in Item 14

Yes

Yes
No

14) Account or Client Number: _______________________________________________ (if available)
We use this information to determine which company you are complaining about and to help make sure the
company reviews the correct account. The more information you provide, the faster we are able to process
this form and take action on this issue.
Telephone: ________________________
15) Information about the Company *
*Company Name: _________________________________________ Website: _________________________
*Address 1: ______________________________________________
Address 2: ______________________________________________
*City: _______________________ *State: _____ *Zip Code: _______ Country: _________________________

16) Have you done any of these things to try to resolve this issue? Check all that apply and provide details below.
Contacted company directly
Contacted Consumer Financial Protection Bureau
Contacted another government agency

Hired an attorney
Filed legal action
Other: _________________________________________

Provide details such as the names of any government agencies contacted, the dates contacted, any case numbers,
contact information, current status, attorney contact information (if applicable), etc.

17) I am filling out this form on behalf of:*
Myself
Myself and Someone Else
Someone Else
COMPLETE THIS SECTION ONLY IF FILING ON BEHALF OF SOMEONE ELSE
*What is your relationship to this person?_________________________________
Please provide us with your name and contact information:
Salutation: _________ (Mr., Mrs., Ms., Dr., etc.)
*First Name: ___________________________________
Middle Name: _________________________________
*Last Name: ___________________________________ Suffix: ________ (Jr., Sr., etc.)
*Mailing Address: _______________________________________________________
*City: __________________________ *State: ______*Zip Code/APO/FPO: _________
*Country: ___________________________________
Phone Number: ________________________ Is this a mobile phone?:
No
Yes
Email Address: ________________________________________________________
18) Account Contact Information * Enter the name(s) and address associated with this account.
Salutation: _________ (Mr., Mrs., Ms., Dr., etc.)
Salutation: _________ (Mr., Mrs., Ms., Dr., etc.)
*First Name: ___________________________________ First Name: __________________________________
Middle Name: _________________________________ Middle Name: ________________________________
*Last Name: ___________________________________ Last Name: __________________________________
Suffix: ________ (Jr., Sr., etc.)
Suffix: ________ (Jr., Sr., etc.)
*Billing Address: ________________________________________________
*City: _______________________ *State: ______*Zip Code/APO/FPO: _________ *Country: ______________
Mailing Address: _______________________________________________ (if different from Billing Address)
City: _______________________ State: ______ Zip Code/APO/FPO: _________ Country: ______________
19) Other Contact Information and Communication Preferences
No
Phone Number: ___________________________ Is this a mobile phone?: Yes
Text
Phone
Mail
Email
Best Way to Contact:
Preferred Language: ______________
Best Time to Contact:
Noon - 4pm ET
4pm - 7pm ET
8am - Noon ET
Email Address: ________________________________________________

20) My age is ________

Prefer Not to Answer
Yes

21) Is this complaint for a servicemember or dependent or spouse of a servicemember?

No

COMPLETE THIS SECTION ONLY IF COMPLAINT IS FOR A SERVICEMEMBER / DEPENDENT OF A SERVICEMEMBER

I am or was a servicemember
I am a dependent or spouse of a servicemember

What is the servicemember’s status?
Retired
Active
Veteran
Reserve
National Guard

Servicemember’s Name:
Salutation: _________ (Mr., Mrs., Ms., Dr., etc.)
*First Name: ______________________________________ What is the servicemember’s branch of service?
Army
Coast Guard
Middle Name: ____________________________________
Navy
Public Health Service
Marines
National Oceanic and
*Last Name: ______________________________________
Air Force
Atmospheric Administration
Suffix: ________ (Jr., Sr., etc.)
*Address: ________________________________________ What is the servicemember’s rank?
E1-E4
O1-O3
W01-CW5
*City: _____________________________ *State: ________
E5-E7
O4-O6
*Zip Code/APO/FPO: ___________ *Country: ____________
E8-E9
O7-O10
24) If you are completing this form about a mortgage issue, please answer these questions.
Are you concerned about losing your home to foreclosure?

Yes

No

Have you missed any mortgage payments or are you in default on your mortgage?

Yes

No

Also check “Yes” if your mortgage company believes you are in default or have missed payments,
even if you believe your mortgage company is in error.

Is there a date that is scheduled for the foreclosure sale of your home?

Yes

No

Don’t Know

If a foreclosure sale has been scheduled, you might have received a Notice of Sale or Order Setting Sale.

If yes, what is the date of the scheduled foreclosure sale?

____ / ____ / ________

Please provide the exact date, if you can. This should be on the Notice of Sale or the Order Setting Sale.

Some companies may charge homeowners a fee for services described as foreclosure defense,
foreclosure prevention, foreclosure rescue, or loss mitigation assistance. Did you hire one of
these companies to help you avoid foreclosure?

Yes

No

The information given is true to the best of my knowledge and belief. I understand that
the CFPB cannot act as my lawyer, a court of law or a financial advisor.*
Privacy Act Statement
The information that you provide will permit the Consumer Financial Protection Bureau to respond to consumer complaints and
inquiries regarding practices by banks and other institutions supervised by the Consumer Financial Protection Bureau. The information
may be disclosed:
 to an entity that is the subject of a complaint or inquiry;
 to a court, magistrate or administrative tribunal in the course of a proceeding;
 to third parties to the extent necessary to obtain information that is relevant to the resolution of a complaint or inquiry;
 for enforcement, statutory, and regulatory purposes;
 to another federal or state agency or regulatory authority;
 to a member of Congress; to the Department of Justice, a court, an adjudicative body or administrative tribunal, or a party in
litigation; and
 to contractors, agents, and others.
This collection of information is authorized by 12 U.S.C. § 5493, 12 C.F.R. Part 1070.
You are not required to file a complaint or inquiry and you may withdraw your complaint or inquiry at any time. However, if you do so,
the Consumer Financial Protection Bureau may not be able to investigate your complaint or inquiry.

Notice of Consumer Information Collection
An agency may not conduct or sponsor, and a person in 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 XXXX–XXXX. This collection expires on XX/XX/XXXX.