Customer Complaint Form

OMB Control No. 1557- 0232
Expiration Date: 11/30/2015

CUSTOMER COMPLAINT FORM

Please fill in this form completely. Mail or fax this completed complaint form to:

Office of the Comptroller of the Currency
Customer Assistance Group
1301 McKinney Street, Suite 3450
Houston, TX 77010-9050
1-713-336-4301 (Fax)

Once we receive your completed form, you will receive an acknowledgment letter containing your
assigned case number. Please keep your case number for future contact with our office.

Helpful Hints:

Check to make sure your financial institution is a national bank or federal savings association
(thrift). If you do not know the name of your financial institution, check your account statement.
The financial institution’s name will be indicated on the statement.

Have you tried to resolve your complaint with your financial institution? The OCC recommends
that you attempt to resolve your complaint with your financial institution first. Please contact
your financial institution to allow them the opportunity to resolve your issue(s).

If your complaint involves more than one financial institution, you will need to submit a separate
complaint form for each institution involved. You will receive separate case numbers for each
institution.

Please Note:

We cannot act as a court of law or as a lawyer on your behalf
We cannot give you legal advice
We cannot become involved in complaints that are in litigation or have been litigated

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YOUR INFORMATION

The Account Owner/Holder should complete this section. * - Indicates Required Fields

*First Name:

Middle Name:

*Last Name:

*Street Address:

*City:

*State:

*Zip:

*Phone:

Email:

What is the best way to contact you? Phone

Mail

Email

What is the best time to contact you? Morning

Afternoon

Evening

REPRESENTATIVE CONTACT INFORMATION

If you want us to communicate with your attorney or other legal representative directly, please provide
the information below. Your submission of this portion of the form authorizes our office to
release information to your attorney or other legal representative if requested. Please check the
following to indicate the type of relationship:

Attorney

Legal Representative

Please indicate the type of authorization you have granted to your attorney or other legal
representative:

Power of Attorney

Letters Testamentary

Court Appointed Executor or Administrator

Other

If you are not sure of the type of legal authorization granted, please check your legal documents or consult with your attorney or other legal
representative.

Name of Representative:

*First Name:

Middle Name:

*Last Name:

*Street Address:

*City:

*State:

*Zip:

*Phone:

Representative Email:

What is the best way to contact your representative? Phone

Mail

Email

What is the best time to contact your representative? Morning

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Afternoon

Evening

FINANCIAL INSTITUTION OR COMPAN Y INFORMATION THAT IS S UBJECT OF THE
COMPLAINT

Helpful Hint: If you do not know the name of your financial institution, check your account statement.
The financial institution’s name will be indicated on the account statement.

*Name of Financial Institution or Company:

Street Address:

*City:

*State:

Zip:

Phone:

*Type of Account(s) (Check all that apply): Deposit Account (Checking, Savings)

Credit Card

Loan Product (Consumer, Mortgage, Home Equity)

Asset Management (Trust Accounts)

Consumer Leasing

Non-Deposit Account (Investments)

Insurance

Other

Have you tried to resolve your complaint with your financial institution or company? Yes

If Yes, when?

How? Phone

Mail

In Person

Other

In Person

Other

Contact Name:

Title:

Has your financial institution responded to you? Yes

If Yes, when?

No

How? Phone

Mail

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No

COMPLAINT INFORMATION

Describe events in the order they occurred, including any names, phone numbers, and a full description
of the problem with the amount(s) and date(s) of any transaction(s). Be as brief and complete as
possible to make the explanation clear. Do not include personal or confidential information such
as your social security, credit card, or account numbers.

Please be advised that the issues described in this complaint will be shared with the financial institution
or company in question.

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PRIVACY ACT STA TEMENT

The solicitation and collection of this information is authorized by 12 U.S.C. 1. The information is
solicited to provide the Office of the Comptroller of the Currency (OCC) with data that is necessary and
useful in reviewing requests received from individuals for assistance in their interactions with national
banks or federal savings associations (thrifts). The provision of requested information is voluntary.
However, without such information, the ability to complete a review or to provide requested assistance
may be hindered.
It is intended that the information obtained through this solicitation will be used within the OCC and
provided to the national bank or federal savings association (thrift) that is the subject of the complaint or
inquiry. Additional disclosures of such information may be made to: (1) other third parties when
required or authorized by statute or when necessary in order to obtain additional information relating to
the complaint or inquiry; (2) other governmental, self-regulatory, or professional organizations having:
(a) jurisdiction over the subject matter of the complaint or inquiry; (b) jurisdiction over the entity that is
the subject of the complaint or inquiry; or (c) whenever such information is relevant to a known or
suspected violation of law or licensing standard for which another organization has jurisdiction; (3) the
Department of Justice, a court, an adjudicative body, a party in litigation, or a witness when relevant
and necessary to a legal or administrative proceeding; (4) a Congressional office when the information
is relevant to an inquiry initiated on behalf of its provider; (5) Other governmental or tribal organizations
with which an individual has communicated regarding a complaint or inquiry about an OCC-regulated
entity; (6) OCC contractors or agents when access to such information is necessary; and (7) other third
parties when required or authorized by statute.

I certify that the information provided on this form is true and correct to the best of my
knowledge.

I Certify

I Do Not Certify

Date:

Signature:

We will mail you a written acknowledgment within five (5) business days of receipt of your completed
complaint form containing your assigned case number. Please utilize your case number for future
contact with our office. If you have any questions regarding this case, please call 1-800-613-6743.

If a valid OMB Control Number does not appear on this form, you are not required to complete this form.

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