TDF 104.3 Consumer Response Intake Form

Submit a complaint
ABOUT A FINANCIAL PRODUCT OR SERVICE

How to submit
Online (recommended)
consumerfinance.gov/complaint

Over the phone
(855) 411-CFPB (2372)

By mail
Consumer Financial Protection Bureau
PO Box 4503, Iowa City, IA 52244

By fax
(855) 237-2392

The complaint process
Complaint
submitted

You submit a complaint about an issue you have with a company about a
consumer financial product or service. You will receive email updates and can
log in to track the status of your complaint.

Review
and route

We'll forward your complaint to the company and work to get a response from
them. If we find that another government agency would be better able to assist,
we will forward your complaint to them and let you know.

Company
response

The company will review your complaint, communicate with you as needed, and
report back about the steps taken or that will be taken on the issue you identify
in your complaint.

Consumer
review

We will let you know when the company responds. You can review that response
and give us feedback.

Review and
investigate

Complaint data is shared with state and federal law enforcement agencies.
Complaints tell us about business practices that may pose risks to consumers.
If we need more information, we’ll reach out and let you know.

Analyze
and report

Complaints help with our work to supervise companies, enforce federal consumer
financial laws, and write better rules and regulations. We also report to Congress
about the complaints we receive and post some consumer complaint data.

Complaint number

need help with this form?
(855) 411- CFPB (2372)

VERSIOn 3.1 / 2014

SUBMIT A COMPLAINT ABOUT A FINANCIAL PRODUCT OR SERVICE

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What happened?
We want to understand your situation to help pinpoint what went wrong. Including facts and details like dates and
where transactions happened can help.
1

Describe what
happened so we
can understand the
issue...
Avoid including any of
your personal contact
information here.
We will collect your
personal information
at a later step.

Desired resolution
We want to understand what you think would be a fair resolution to the issue. We’ll forward this information to the
company along with your description of what happened so that all parties involved can understand what you’re
looking for.
2

What do you think
would be a fair
resolution to your
issue?
Avoid including any of
your personal contact
information here.
We will collect your
personal information
at a later step.

Complaint number

need help with this form?
(855) 411- CFPB (2372)

2 OF 7

SUBMIT A COMPLAINT ABOUT A FINANCIAL PRODUCT OR SERVICE

Product or service type
3

What is your
complaint about?

bank account or service

mortgage

vehicle loan OR lease

Choose one

Credit card

Payday loan

Other Consumer loan

credit reporting

Prepaid card

Other financial service

Money transfer

Student Loan

4

In a few words,
what is your issue
with this product
or service?

5

When did this
happen?

MM

DD

YYYY

OPTIONAL

6

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

$

OPTIONAL

7

Have you done any
of these things to
try to resolve this
issue?
OPTIONAL

contacted company
directly

contacted another
government agency

filed legal action

contacted consumer
financial protection
bureau

hired an attorney

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.

Complaint number

need help with this form?
(855) 411- CFPB (2372)

SUBMIT A COMPLAINT ABOUT A FINANCIAL PRODUCT OR SERVICE

Mortgage questions, if applicable
Filing a complaint will not automatically delay or stop a foreclosure.
If you are not submitting a mortgage complaint, skip this page.
8

Are you concerned
about losing
your home to
foreclosure?

Yes
no

OPTIONAL

9

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

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.

Yes
no

OPTIONAL

10

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

no

OPTIONAL

10a

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

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

Yes

don’t know

MM

DD

YYYY

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

OPTIONAL

11

Did you pay
a company to
help you avoid
foreclosure?

Yes
no

Sometimes called “foreclosure rescue,”
“foreclosure defense,” “foreclosure
prevention,” or “loss mitigation
assistance.”

OPTIONAL

Complaint number

need help with this form?
(855) 411- CFPB (2372)

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SUBMIT A COMPLAINT ABOUT A FINANCIAL PRODUCT OR SERVICE

Personal information
12

I am submitting
on behalf of:

myself

Fill out questions 13, 13a & 14

someone else

13

Account holder’s
information

first name

Fill out questions 13, 13a, 14 & 15

Last name

suffix

Street

City

State

email

13a

Account
holder’s age

Zip code

Country

phone number

age

optional

14

Account number

15

Contact
information of
person submitting
this complaint
If you are submitting
on behalf of someone
else, include your
information here.
We’ll use it to contact
you about the status
of this complaint.

first name

Last name

suffix

Street

City

State

email

Zip code

phone number

Complaint number

need help with this form?
(855) 411- CFPB (2372)

Country

5 OF 7

SUBMIT A COMPLAINT ABOUT A FINANCIAL PRODUCT OR SERVICE

Information about the company
16

Company name

16a

Company address

Street

optional

City

16b

State

Zip code

Country

Phone number
optional

16c

Website
optional

Attach any
supporting
documents

Please attach copies of any documents related to your case. Seeing the full versions of
documents like contracts, letters, monthly statements, and transaction receipts is the best
way for us to really understand your case. Do not include original versions.

Complaint number

need help with this form?
(855) 411- CFPB (2372)

6 OF 7

SUBMIT A COMPLAINT ABOUT A FINANCIAL PRODUCT OR SERVICE

Military affiliation, if applicable
There are certain protections that apply to servicemembers and their spouses and dependents.
If you have no affiliation with the military, skip this page.
17

The account holder
is now or was:

A servicemember

Optional,

The spouse / dependent of a servicemember

Fill out question 17a
Fill out questions 17a & 17B

Check all that apply

17a

Service details

Current status

Branch

Rank

optional,
choose one
in each column

17b

Servicemember
personal
information

Active

Army

E1 - E4

Reserve

Navy

e5 - e7

National Guard

Marines

e8 - e9

Retired

Air Force

o1 - o3

Veteran

Coast Guard

o4 - o6

Public Health Service

o7 - o10

National Oceanic &
Atmospheric Admin

w01 - CW5

first name

Last name

suffix

optional
Street

City

State

Complaint number

need help with this form?
(855) 411- CFPB (2372)

Zip code

Country

SUBMIT A COMPLAINT ABOUT A FINANCIAL PRODUCT OR SERVICE

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Certify
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 you provide will permit the Consumer
Financial Protection Bureau to respond to your complaint
or inquiry about companies and services we supervise.
Information about your complaint or inquiry (including
your personally identifiable information) may be shared:

▪
▪
▪
▪
▪

with the entity that is the subject of your complaint;
with third parties as necessary to get information
relevant to resolving a complaint;
with a court, a part in litigation, a magistrate, an
adjudicative body or administrative tribunal in the
course of a proceeding or the Department of Justice;
with other federal or state agencies or regulatory
authorities for enforcement and statutory purposes;
and
with contractors, agents, and others authorized by
the CFPB to receive this information.

We may also share your complaint or inquiry (but not
your personally identifiable information) with the public
through a public complaint database.
This collection of information is authorized by 12 U.S.C. §
5493.
You are not required to file a complaint or share any
identifying information, including your social security
number, and you may withdraw your complaint at any
time. However, if you do not include the requested
information, the CFPB may not be able to act on your
complaint.

Notice of Consumer Information Collection
This is how we accept complaints. You’re not required to
fill out this form if you don’t want to submit a complaint.
We estimate that it takes about 7 to 10 minutes to finish
completing the form. Our OMB control number for this
form is 3170-0011 and expires on 5/31/2015. Comments
or suggestions? Email us at [email protected].

Complaint number

need help with this form?
(855) 411- CFPB (2372)