Consumer Financial Protect Bureau (CFPB) Consumer Complaint Intake System Company Portal Boarding Form

Generic Clearance for Consumer Complaint and Information Collection System (Testing and Feedback)

Consumer Response's Company Portal Boarding Form FINAL

Consumer Financial Protect Bureau (CFPB) Consumer Complaint Intake System Company Portal Boarding Form

OMB: 3170-0042

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3170-0042 can be found here:

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Notice of Collection under the Privacy Act of 1974, 5 U.S.C. § 552a
As Amended (Privacy Act Notice)
The information that you provide to the Consumer Financial Protection Bureau (CFPB) will be used to create a user account
so that you may log on to the web-based company portal for the CFPB’s Office of Consumer Response. Account access to
the web-based company portal will enable you to view complaints or inquiries filed against your company with the CFPB
and allow you to respond to the complaints or inquiries. The information you provide may be shared:

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to a court, magistrate, or administrative tribunal in the course of a proceeding;
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
pursuant to the CFPB’s published Privacy Act System of records notice, CFPB.005- Consumer Response System.

We may also share the response you submit regarding your company and its business activities (but not personally
identifiable information) with the public through the Public Complaint Database.
You are not required to submit or provide any identifying information; however, if you do not include the requested
information you may not be granted access to the company portal.
The collection of information is authorized by Public Law III-203, Title X, Sections 1011, 1012, 1013 (b)(3), 1021, 1034,
codified at 12 U.S.C. 5491, 5492, 5493(b)(3), 5511, 5534.

Consumer Response’s Company Portal
Boarding Form
To allow your company access to the consumer complaints submitted against it through the
Consumer Financial Protection Bureau (CFPB), complete the required sections of this form. The
information requested will help us to set up your company portal, provide access to the portal
for any company-authorized individual, and to route complaints efficiently to your portal. Once
you have completed the form you may submit the form by emailing the form to:
[email protected].

Section A: Company Information

This section is required. Please fill out the information in this section as it relates to your
company.

Enter the full name of your company:

Click here to enter text.

Is your company or a portion of your company owned by another company, often referred to as a parent
company?
 Yes
 No
ANSWER THESE QUESTIONS ONLY IF YOU ANSWERED “Yes” TO QUESTION 2
2a. Please enter the full name of your parent company:

Click here to enter text.

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2b. Please list a point of contact (POC) for your parent company:

Click here to enter text.

2c. Please list a contact phone number or email address for the POC:

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3.

4.
5.

Indicate the business structure of your company:
 Corporation
 Limited Liability Company
 Partnership
 S Corporation
 Sole Proprietorship
Enter your company’s tax ID:

Click here to enter text.

Is this tax ID also a Social Security Number (SSN)?
 Yes
 No
Enter your company’s Financial Institution Number (FIN) (if your company does not have a FIN, list “N/A”):

Please list your company’s URL or website:

Click here to enter text.
Click here to enter text.

Is this a web-based business (a web-based business is a business whose products or services are offered only
through the internet)?
 Yes
 No
9. Please list the mailing address of your company’s headquarters (this should NOT be a P.O. Box):
Street Address:
City:

Click here to enter text.

State:

Zip:

Choose an item.

Click here to enter text.

10. Does this address also reflect your state of incorporation or home state of business?
 Yes (If “Yes,” skip to question 14)
 No
ANSWER THIS QUESTION ONLY IF YOU ANSWERED “No” TO QUESTION 10
10a. Please select the state of incorporation or home state of business for your company:

Choose an item.

11. Please list any state business licenses your company has and indicate the state for which the license is valid:
(If you need more rows than listed, please use the additional sheets at the end of the form.)
State Business License Number:
State for which the license is valid:

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Section B: Contact Information

This section is required. The authorized company officer or their designee will be the main
point of contact for the CFPB and will be the only authorized personnel to add or remove users
from the company portal maintained by the CFPB.

12. Please list the full name of the authorized officer/employee:

Click here to enter text.

13. Please list the title of the authorized officer/employee:

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14. Please list the phone number of the authorized officer/employee:

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15. Please list the email of the authorized officer/employee:

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16. If the authorized officer/employee is unavailable, please list the full name of the official designee:

Click here to enter text.

17. Please list the email of the official designee:

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18. Please list the phone number of the official designee:

Click here to enter text.

Section C: Portal Users Information

This section is required. The following information is needed to setup the user profiles for each
company-authorized individual. Enter the information necessary for all users that need access
to the company portal. Please provide information on each person you designate as a user.

19. Are the authorized officer/employee (from Section B) and designee, if named, the only portal users?
 Yes
 No (If “No,” please fill out the following section for each portal user.)
ANSWER THESE QUESTIONS ONLY IF YOU ANSWERED “No” TO QUESTION 24
Portal User 1:
First and Last Name:
Title/Position:

Click here to enter text.

Phone number:

Email:

Click here to enter text.

Will this person need to export data into Excel or some other file?
 Yes
 No
Portal User 2:
First and Last Name:
Title/Position:

Click here to enter text.

Phone number:

Email:

Click here to enter text.

Will this person need to export data into Excel or some other file?
 Yes
 No
Portal User 3:
First and Last Name:
Title/Position:

Click here to enter text.

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Phone number:

Click here to enter text.

Email:

Click here to enter text.

Will this person need to export data into Excel or some other file?
 Yes
 No
Portal User 4:
First and Last Name:
Title/Position:

Click here to enter text.

Phone number:

Email:

Click here to enter text.

Will this person need to export data into Excel or some other file?
 Yes
 No
Portal User 5:
First and Last Name:
Title/Position:

Click here to enter text.

Phone number:

Email:

Click here to enter text.

Will this person need to export data into Excel or some other file?
 Yes
 No

Section D: Affiliates and Subsidiaries Information

This section is required. The following information is needed to effectively route consumer
complaints against these affiliates and subsidiaries. Please provide information on any
subsidiary or affiliate companies the parent company may have.

20. Does your company have any affiliates or subsidiaries?
 Yes (If “Yes,” please fill out the section below for each affiliate or subsidiary.)
 No
ANSWER THESE QUESTION ONLY IF YOU HAVE ANSWERED “Yes” TO QUESTION 25
Affiliate or Subsidiary Information:
Name of Affiliate or Subsidiary:
Tax ID of Affiliate or Subsidiary:

Click here to enter text.

Is this tax id a Social Security Number (SSN)?
 Yes
 No
Please list any information regarding the state business licenses for the affiliate:
State Business License Number
State for which it is valid
Entity or individual for which it is registered

Click here to enter text.
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Affiliate or Subsidiary Information:
Name of Affiliate or Subsidiary:

Click here to enter text.

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Tax ID of Affiliate or Subsidiary:

Click here to enter text.

Is this tax id a Social Security Number (SSN)?
 Yes
 No
Please list any information regarding the state business licenses for the affiliate:

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State Business License Number

State for which it is valid

Entity or individual for which it is registered

Click here to enter text.
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Affiliate or Subsidiary Information:
Name of Affiliate or Subsidiary:

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Tax ID of Affiliate or Subsidiary:

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Affiliate or Subsidiary Information:
Name of Affiliate or Subsidiary:

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Tax ID of Affiliate or Subsidiary:

Click here to enter text.

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Affiliate or Subsidiary Information:
Name of Affiliate or Subsidiary:

Click here to enter text.

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Tax ID of Affiliate or Subsidiary:

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Approved for use through MM/DD/YYYY by OMB Control No. 3170-0042

Section E: Products/Service Information

This section is required. The following information is needed to effectively route consumer
complaints against these products/services.

21. What is your company’s primary product (select one)?
 Credit Cards

 Mortgages

 Bank Accounts Services

 Consumer Loans

 Private Student Loans


Payday Loans
Credit Reporting
Money Transfers
Debt Collection
Prepaid Cards

Section F: Company Logo

Please attach a copy of your company’s logo/provide an electronic copy of your company’s logo.
 By checking this box, you indicate that your company grants the CFPB permission to depict on the
Consumer Complaint Intake Form your company’s logo and/or mark, for the limited purpose of prompting
consumers who file online complaints with the CFPB to accurately identify the company that is the subject of
their complaint. The CFPB anticipates that this use of company logos will ensure a correct match between
the consumer and the company that is the subject of their complaint and will support a more efficient
complaint handling process.
If you do not check this box, the CFPB will not use your company’s logo to assist consumers with company
identification.

Section G: Submit

 By clicking this box, you are indicating that you believe the information provided to be true to the
best of your knowledge and belief.
To submit, save this completed form and attach it in an email to [email protected].

For Internal Use Only

This section is for internal notes.
Internal Use Only.

Approved for use through MM/DD/YYYY by OMB Control No. 3170-0042

Additional Supplements to On-Boarding Form

Section A. Company Information - Supplement
14. Please list any state business licenses your company has and indicate the state for which the license is valid.
State Business License Number:
State for which the license is valid:

Click here to enter text.
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Paperwork Reduction Act Statement
We estimate it takes about 15 minutes to complete the form with enough information to provide portal access. 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 3170-0042, expires 5/31/2015.
Comments regarding this collection of information, including the estimated response time, suggestions for
improving the usefulness of the information, or suggestions for reducing the burden to respond to this collection
should be submitted to Consumer Financial Protection Bureau (Attention: PRA Office), 1700 G Street NW,
Washington, DC 20552, or by email to [email protected].

Approved for use through MM/DD/YYYY by OMB Control No. 3170-0042

File Type	application/pdf
Author	Schwartz, Dana
File Modified	2014-11-12
File Created	2014-11-12