TDF 104.3 Consumer Response Intake Form

Consumer Assistance Form
You should fill out this form if you have a complaint, comment, or ques on about a financial ins tu on, financial
product, or financial service, or the Consumer Financial Protec on Bureau (CFPB). The more informa on you
provide, the be er we will be able to understand your issue. Please fill in this form completely and mail or fax to:
The Consumer Financial Protec on Bureau
PO Box 4503
Iowa City, IA 52244
Fax: 855‐CFPB‐FAX (855‐237‐2392)
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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 informa on from this form to the company you iden fy. You
can submit informa on anonymously, but we may not be able to take ac on. 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, wri en permission
to take ac on. 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 ins tu on, 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
ins tu on, product, service, or
prac ce 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 Ques on about a
financial ins tu on, product,
service, or prac ce or the
CFPB
Tell us your ques on or comment.*  
Complete Item 2 and skip to Item 19 

Yes

No

4) Is this about something you observed while working for a financial ins tu on or financial service provider?*
      Employees of a bank or other consumer financial service provider may be en tled to
No
Yes
certain protec ons. For more informa on visit www.whistleblowers.gov.
If yes, skip to Item 11
* Answers to these ques ons are necessary for the CFPB to take ac on 

5) This is about:*        Check only one.
Credit Repor ng 
Credit Products 
Credit Card
Payday Loan
Cash Advance Loan
Student Loan ‐ Federal
Student Loan ‐ Private
Tax Refund An cipa on Loan
Car / Auto Loan
Car Title Loan

Mortgage/Home Loan 
Conven onal Adjustable
Mortgage (ARM)
Conven onal Fixed Mortgage
FHA Mortgage
Home Equity Loan / Line of Credit
Reverse Mortgage
VA Mortgage
Other: ____________

Credit Report / Credit Score
Informa on Given to Credit
Repor ng Agency

Deposit Products 
Checking Account
Savings Account
Cer ficate of Deposit (CD)
Money Market Account
Deposit Insurance

Methods of Payment 
ACH Transfer
ATM/Debit Card
Check Cashing
Checks
Currency Exchange
Gi Card
Money Order
Money Transmission or Remi ance
Prepaid Card / Stored Value Card

Financial Advisory Service 
Credit Counseling
Debt Management/Se lement
Investment Advice (not broker‐dealer)
Financial Planner

Property Development 
Se lement Service
Subdivision/Condo Development

Other 
Debt Collec on
Consumer Leasing
Iden ty The
Individual Re rement Account (IRA)
Pawn Broker
Safe Deposit Box
Other: ________________________

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

Yes

No

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

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

Don’t Know

9) Es mate the total dollar value of your loss based on what you know right now.  $ ____________
10) What do you think would be a fair resolu on of this issue?* _______________________________________
_________________________________________________________________________________________ 
11) I want to submit anonymously. I understand the CFPB may not be able to respond or take ac on.*  
       If yes, skip to Item 15 
Yes

No

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

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 informa on to determine which company you are complaining about and to help make sure the
company reviews the correct account. The more informa on you provide, the faster we are able to process
this form and take ac on on this issue.
Telephone: ________________________
15) Informa on 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 Protec on Bureau
Contacted another government agency

Hired an a orney
Filed legal ac on
Other: _________________________________________

Provide details such as the names of any government agencies contacted, the dates contacted, any case numbers,
contact informa on, current status, a orney contact informa on (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 rela onship to this person?_________________________________
Please provide us with your name and contact informa on: 
Saluta on: _________ (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?: Yes
No
Email Address: ________________________________________________________
18) Account Contact Informa on *  Enter the name(s) and address associated with this account.
Saluta on: _________ (Mr., Mrs., Ms., Dr., etc.)
Saluta on: _________ (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 Informa on and Communica on Preferences
No
Phone Number: ___________________________ Is this a mobile phone?: Yes
Text
Phone
Mail
Email
Best Way to Contact:
Preferred Language: ______________
Noon ‐ 4pm ET
4pm ‐ 7pm ET
Best Time to Contact:
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 of a servicemember

What is the servicemember’s status?
Re red
Ac ve
Veteran
Reserve
Na onal Guard

Servicemember’s Name:
Saluta on: _________ (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
Na onal Oceanic and
*Last Name: ______________________________________
Air Force
Atmospheric Administra on
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 comple ng this form about a mortgage issue, please answer these ques ons. 
Yes

No

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

No

Are you concerned about losing your home to foreclosure? 
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 No ce of Sale or Order Se ng 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 No ce of Sale or the Order Se ng Sale.

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

No

 The informa on 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 informa on you provide will permit the Consumer Financial Protec on Bureau to respond to your complaint or inquiry about com‐
panies and services we supervise. Informa on about your complaint or inquiry (including your personally iden fiable informa on) may
be shared:
 with the en ty that is the subject of your complaint;
 with third par es as necessary to get informa on relevant to resolving a complaint;
 with a court, a party in li ga on, a magistrate, an adjudica ve body or administra ve tribunal in the course of a proceeding, or the
Department of Jus ce;
 with other federal or state agencies or regulatory authori es for enforcement and statutory purposes; and
 with contractors, agents, and others authorized by the CFPB to receive this informa on.
We may also share your complaint or inquiry (but not your personally iden fiable informa on) with the public through a public com‐
plaint database.
This collec on of informa on is authorized by 12 U.S.C. § 5493.
You are not required to file a complaint or share any iden fying informa on, including your Social Security number, and you may with‐
draw your complaint at any me. However, if you do not include the requested informa on, the CFPB may not be able to act on your
complaint.

No ce of Consumer Informa on Collec on 
An agency may not conduct or sponsor, and a person in not required to respond to, a collec on of informa on unless the collec on of
informa on displays a valid control number assigned by the Office of Management and Budget (OMB). The OMB control number for this
collec on is 3170‐0011. This collec on expires on 11/30/2014.