Appendix D: Privacy Statement and Consent Form

Appendix D to Supporting Statement of
Bureau of Consumer Financial Protection
Quantitative Testing of Integrated Mortgage Loan Disclosure Forms
Privacy Statement and Consent Form
The Kleimann Communication Group, Inc. 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. Your participation is voluntary and should take no
more than 60 minutes of your time.
Here is information about the privacy of your information.
 Unless you separately and expressly consent in writing, we will maintain the privacy of
your identity, your participation, and your responses to the questionnaires you fill out
today to the extent permitted by law.
 CFPB will not obtain or access any personally identifiable information, including
demographic information, from us about individual survey participants.
 CFPB will only obtain and access anonymous results and aggregated analyses of those
results. Information collected on behalf of the CFPB by Kleimann Communication Group,
Inc. or GfK’s KnowledgePanel will be treated in accordance with the System of Records
Notice (“SORN”), CFPB.022 – CFPB Market and Consumer Research Records, 77 F.R.
67802, with the CFPB’s confidentiality regulations at 12 C.F.R. Part 1070, and with
KnowledgePanel’s Privacy Statement for KN Panelists from the GfK Knowledge Networks
KnowledgePanel® Website.
 This collection of information is authorized by Pub. L. No. 111-203, Title X, Sections
1022, 1032, 1098, and 1100A.
 For the assurances of confidentiality provided to respondents by Kleimann
Communication Group, Inc. or GfK’s KnowledgePanel, please see:
http://www.knowledgenetworks.com/company/privacy.html (privacy policy). GfK’s
KnowledgePanel will provide information from the respondents to Klenmann
Communication Group, Inc. consistent with this privacy policy.
We thank you for your participation in this important project, which will serve to improve the
communication of required disclosures of important information to American families applying
for and closing a mortgage loan.
I have read this document in full and agree to participate in the voluntary study. By signing, I
acknowledge my voluntary participation in this project.
Name (please print): _____________________________________________________________
Signature: _____________________________________________________________________
Today’s Date: __________________________________________________________________