Updated Screen Shots

Justification for Non-material/Non-substantive Change
Consumer Financial Protection Bureau
Information Collection Request
Consumer Response Intake Form (Intake Form)
OMB No. 3170-0011

The Consumer Financial Protection Bureau (CFPB) submits this memorandum to provide
justification for a proposed change to the form associated with information collection 3170-0011
Consumer Response Intake Form, approved by Office of Management and Budget (OMB) on
November 18, 2011.11 The proposed revision will be reflected on previously- approved
information collection media (i.e., telephone script, “paper” form, and web form) and does not
represent a new collection instrument. For ease of discussion, all reference will be to the attached
screenshots of the web version.
In February 2012, the OMB approved several non-material revisions to the Intake Form, including
the plain language revision of the product and issue description “money transmission or
remittance” to “money transfer.” (The term “money transfer” is more commonly used to refer to
any electronic transfer of money from one person to another.) This memorandum serves to
update the previous submission and provide a more detailed illustration by way of website
screenshots.

1

Originally approved as a Department of Treasury/Department Offices form, the approved information collection
was transferred to Consumer Financial Protection Bureau on November 21, 2011. ICR Reference Number 2011113170-004.

Screenshots for proposed Money Transfers web complaint form
Section 1: What Happened
Screenshot view: Main

Section 1: What Happened
Screenshot view: This is about Domestic (US) money transfer

Section 1: What Happened
Screenshot view: This is about International money transfer

Section 2: Desired Resolution
Screenshot view: Main

Section 3: My Information
Screenshot view: Main

Section 3: My Information
Screenshot view: Select “I am filing on behalf of someone else”; “Servicemember”

Section 4: Product Information
Screenshot view: Main

Section 4: Product Information
Screenshot view: View options for “Where did the transaction take place”

Section 4: Product Information
Screenshot view: “Where did the transaction take place”: Online

Section 4: Product Information
Screenshot view: “Where did the transaction take place”: In person, phone, fax

Section 4: Product Information
Screenshot view: Sender Information fields

Section 4: Product Information
Screenshot view: Amount transfer fields

Section 4: Product Information
Screenshot view: Person Receiving Funds Fields

Section 5: Review
Screenshot view: Main 1

Section 5: Review
Screenshot view: Main 2