Consumer Response Intake Instruments

Consumer Response Intake Form

All Consumer Response Intake Instruments v3(FINAL)

Consumer Response Intake Forms

OMB: 3170-0011

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3170-0011 can be found here:

Document [pdf]

Download: pdf | pdf

Consumer Financial Protection Bureau Information Collection Request
OMB Control Number 3170-0011

Web Complaint Intake Forms
•

Credit Card

•

Mortgage

•

Bank Account or Service

•

Student Loan

•

Vehicle or Consumer Loan

•

Credit Reporting

•

Money Transfer

•

Debt Collection

•

Payday & Other Consumer Loans

•

Prepaid

•

Other Financial Services

External Party Logins
•

Consumer Portal Login

•

Company & Government Login

Feedback Intake Form
•

Web Tell Your Story form

Paper Intake Forms
•

Universal complaint intake form (English and Spanish)

•

Debt collection complaint intake form (English and Spanish)

Phone complaint, inquiry and feedback intake
•

Phone scripts

File a credit card complaint
We'll forward your issue to your credit card company, give you a tracking number, and keep you
updated on the status of your complaint.

1. What
happened?

2. Desired
resolution

3. My
information

4. Product
information

5. Review

For credit card issues affecting your credit report, submit your complaint here.

Describe what happened so we can understand the issue... *
Do not include sensitive information like your name, contact information, account number, or social
security number in this field. We will collect certain personal information at a later step.

This is the what happened field

3869 characters remaining
I want the CFPB to publish this description on consumerfinance.gov so that others can learn from
my experience with this company. I understand that there is a small chance that someone may be
able to identify me based on the information I've included.
Learn more.

Which of these best describes your issue? *
Application processing delay
If you lost money, how much money did you lose? (Optional)
$ 0
When did this happen? 3/1/2015

(Optional)

Have you done any of these things to try to resolve this issue? (Optional)
Contacted the company
directly
Contacted the Consumer Financial Protection Bureau
previously

Form trouble?
Chat now.

previously
Contacted another government
agency
Hired an
attorney
Filed legal
action

Save
Privacy act statement

OMB #3170-0011

File a credit card complaint
We'll forward your issue to your credit card company, give you a tracking number, and keep you
updated on the status of your complaint.

✓ What
happened?

2. Desired
resolution

3. My
information

4. Product
information

5. Review

What do you think would be a fair resolution to your issue? *
Do not include sensitive information like your name, contact information, account number, or social
security number in this field. We will collect certain personal information at a later step.

This is the desired resolution

3870 characters remaining

Save
Privacy act statement

OMB #3170-0011

Form trouble?
Chat now.

File a credit card complaint
We'll forward your issue to your credit card company, give you a tracking number, and keep you
updated on the status of your complaint.

✓ What
happened?

✓ Desired
resolution

3. My
information

4. Product
information

5. Review

Select both boxes if submitting this complaint for a joint account. Select "Someone else" if assisting
someone in submitting a complaint. Provide your information under "My contact information" and the
other person’s information under "Someone else".
I am submitting on behalf of

Myself

Someone else

Submitting on behalf of someone else may require signed, written permission.

My contact information
Salutation (Optional)
First name
Name*
Last name
Name*
Suffix (Optional)
Mailing
Mailing address
Address*
Apartment,
Apartment, suite,
suite,building
building(Optional)
(Optional)
City *
State *
Zip
ZIP code
code *
United States
Phone
Phone (Optional)
(Optional)
Email *

Someone else
What is your relationship to this person?*

Choose...

Form trouble?
Chat now.

Salutation (Optional)
First name
name *
Last name
name *
Suffix (Optional)
Mailing
Mailing address
Address*
Apartment,
Apartment, suite,
suite,building
building(Optional)
(Optional)
City *
State *
Zip
ZIP code
code *
United States
Phone
Phone (Optional)
(Optional)
Email (Optional)
(Optional)
Account Holder's age is

(Optional)

The consumer is a servicemember or is a spouse or dependent of a servicemember. (Optional)
Servicemember
Dependent or spouse of a
servicemember
What is the servicemember's status?*

Choose...
What is the service?*

Choose...
What is the servicemember's rank?*

Choose...

Continue
Privacy act statement

Back
OMB #3170-0011

File a credit card complaint
We'll forward your issue to your credit card company, give you a tracking number, and keep you
updated on the status of your complaint.

✓ What
happened?

✓ Desired
resolution

✓ My
information

Billing address same as mailing
address.

Billing address
Billing
Billing address
Address*
Apartment,
Apartment, suite,
suite,building
building(Optional)
(Optional)
City *
State *
Zip
ZIP code
Code*
United States

Name
Name on
on account
Account
Credit
Credit card
cardnumber
number
For account identification only. You will not be charged.

Information about the company
Company
Company name
Name*
The company name you entered is not in our database.
Please enter in the optional address information.

Company
Company address
Address(Optional)
(Optional)
City (Optional)
(Optional)
State (Optional)
Zip
ZIP code
Code(Optional)
United States

4. Product
information

5. Review

Form trouble?
Chat now.

Do not submit a complaint if you do not want it to be forwarded to the company you select. All
complaints submitted on this site will be sent to the company for response.

Upload any supporting documents (Optional)
Account agreements, monthly statements, proof of payment, etc.

Attach documents
Attach

Documents must be attached to your complaint before submission. Once your complaint is
submitted, you will not be able to add any further documentation. You may submit any document to
support your complaint in all digital file types except executable files (.exe).

Continue
Privacy act statement

Back
OMB #3170-0011

File a credit card complaint
We'll forward your issue to your credit card company, give you a tracking number, and keep you
updated on the status of your complaint.

✓ What
happened?

✓ Desired
resolution

✓ My
information

✓ Product
information

Form trouble?
Chat now.

WHAT HAPPENED [EDIT]
Describe what happened so we can understand the issue...
This is the what happened field
Consent to Publish? Consent provided
Issue Application processing delay
If you lost money, how much money did you lose? $ 0
Date of incident 3/1/2015
Have you done any of these things to try to resolve this issue?
Contacted the company directly
Contacted the the Consumer Financial Protection Bureau previously
Contacted another government agency
Hired an attorney
Filed legal action

DESIRED RESOLUTION [EDIT]
What do you think would be a fair resolution to your issue?
This is the desired resolution

MY INFORMATION [EDIT]
Contact information
Mailing address
Mr First Name Last Name Jr
Mailing Address
Apartment, suite, building (Optional)
City DC Zip code
United States
Email [email protected]
Phone Phone (Optional)
I am submitting on behalf of

5. Review

Myself

Someone else

Someone else
Relationship Family member
First name Last name
Mailing Address
Apartment, suite, building (Optional)
City DC Zip code
United States
Email Email (Optional)
Phone Phone (Optional)

Servicemember information
The consumer is a

Servicemember

Servicemember information
Servicemember status Active
Servicemember branch Army
Servicemember rank W01-CW5

PRODUCT INFORMATION [EDIT]
Billing address
Billing Address
Apartment, suite, building (Optional)
City DC Zip Code
United States
Credit card number ******************
Information about the company
Company Name
Company Address (Optional)
City (Optional)
Zip Code

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.

Submit

Privacy act statement

OMB #3170-0011

File a mortgage complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

1. What
happened?

2. Desired
resolution

3. My
information

4. Product
information

5. Review

This is the what happened field

Which part of the mortgage process is your issue related to? *
Applying for the loan
Application, originator, mortgage broker

Making payments
Loan servicing, payments, escrow accounts

Receiving a credit offer
Credit decision/Underwriting

Problems when you are unable to pay
Loan modification, foreclosure

Signing the agreement
Settlement process and costs
Are you concerned about losing your home to foreclosure?*
Yes

Please note: Filing a complaint will not automatically delay or stop a foreclosure
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
Is there a date scheduled for the foreclosure sale of your home?

Yes

Form trouble?
Chat now.

When is the scheduled foreclosure sale?
You may find this date on the "Notice of Sale" or "Order Setting Sale."

3/1/2015
Did you pay a company to help you avoid
foreclosure?
Sometimes called "foreclosure rescue," "foreclosure defense," "foreclosure prevention," or "loss
mitigation assistance."
Yes
No

My loan is a(n)*

VA mortgage

Continue
Privacy act statement

OMB #3170-0011

File a mortgage complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

2. Desired
resolution

3. My
information

4. Product
information

5. Review

This is the desired resolution field

3864 characters remaining

Continue
Privacy act statement

Back
OMB #3170-0011

Form trouble?
Chat now.

File a mortgage complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

✓ Desired
resolution

3. My
information

4. Product
information

5. Review

Myself

Someone else

Submitting on behalf of someone else may require signed, written permission.

My contact information
Salutation (Optional)
First name
Name*
Last name
Name*
Suffix (Optional)
Mailing
Mailing address
Address*
Apartment,
Apartment, suite,
suite,building
building(Optional)
(Optional)
City *
State *
Zip
ZIP code
Code*
United States
Phone
Phone (Optional)
(Optional)
Email *

Someone else
What is your relationship to this person?*

Choose...

Form trouble?
Chat now.

Salutation (Optional)
First name
name *
Last name
name *
Suffix (Optional)
Mailing
Mailing address
address*
Apartment,
Apartment, suite,
suite,building
building(Optional)
(Optional)
City *
State *
Zip
ZIP code
Code*
United States
Phone
Phone (Optional)
(Optional)
Email (Optional)
(Optional)
Account Holder's age is

(Optional)

The consumer is a servicemember or is a spouse or dependent of a servicemember. (Optional)
Servicemember
Dependent or spouse of a
servicemember

Enter the servicemember information below.

Salutation (Optional)
First name
name *
Middle
Middle name
name(Optional)
(Optional)
Last name
name *
Suffix (Optional)
Address
Address *
Apartment,
Apartment, suite,
suite,building
building(Optional)
(Optional)
City *
State *
Zip
ZIP code
Code*
United States
What is the servicemember's status?*

Choose...
What is the service?*

Choose...
What is the servicemember's rank?*

Choose...

Continue
Privacy act statement

Back
OMB #3170-0011

File a mortgage complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

✓ Desired
resolution

✓ My
information

4. Product
information

5. Review

Property address same as mailing
address.

Property address
Property
Property address
Address*
Apartment,
Apartment, suite,
suite,building
building(Optional)
(Optional)
City *
State *
Zip
ZIP code
Code*
United States

Account/Loan
Account/Loan number
Number
(Optional)
(Optional)
For account identification only

Information about the company
Company
Company name
Name*
The company name you entered is not in our database.
Please enter in the optional address information.

Company
Company address
address(Optional)
(Optional)
City (Optional)
(Optional)
State (Optional)
Zip
ZIP code
code (Optional)
United States
Do not submit a complaint if you do not want it to be forwarded to the company you select. All
complaints submitted on this site will be sent to the company for response.

Form trouble?
Chat now.

Upload any supporting documents (Optional)
Mortgage statements, good faith estimates, loan origination documents, etc.

Attach documents
Attach

Continue
Privacy act statement

Back
OMB #3170-0011

File a mortgage complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

✓ Desired
resolution

✓ My
information

✓ Product
information

5. Review

Form trouble?
Chat now.

WHAT HAPPENED [EDIT]
Describe what happened so we can understand the issue...
This is the what happened field
Consent to Publish? Consent provided
Which part of the mortgage process is your issue related to?
Problems when you are unable to pay
Are you concerned about losing your home to foreclosure? Yes

Have you missed any mortgage payments or are you in default on your mortgage? Yes
Is there a date scheduled for the foreclosure sale of your home? Yes
When is the scheduled foreclosure sale? 3/1/2015
Did you pay a company to help you avoid foreclosure? Yes
This is about VA mortgage

DESIRED RESOLUTION [EDIT]
What do you think would be a fair resolution to your issue?
This is the desired resolution field

MY INFORMATION [EDIT]
Contact information
Mailing address
First Name Last Name
Mailing Address
Apartment, suite, building (Optional)
City DC Zip Code
United States
Email [email protected]
Phone Phone (Optional)
I am submitting on behalf of

Someone else

Myself

Someone else

Relationship Advocate
First name Last name
Mailing address
Apartment, suite, building (Optional)
City DC Zip Code
United States
Email Email (Optional)
Phone Phone (Optional)

Servicemember information
Dependent or spouse of a servicemember
Dependent information
First name Last name
Address
Apartment, suite, building (Optional)
City DC Zip Code
United States
Servicemember information
Servicemember status Retired
Servicemember branch Navy
Servicemember rank E5-E7

PRODUCT INFORMATION [EDIT]
Property address is the same as mailing address.
Account/Loan number ******************************
Information about the company
Company Name
Company address (Optional)
City (Optional) Zip code

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.

Submit

Privacy act statement

OMB #3170-0011

File a bank account or service complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

1. What
happened?

2. Desired
resolution

3. My
information

4. Product
information

5. Review

This is the what happened field

This is about a(n) *
Checking account
Which of these best describes your issue? *
Account opening, closing, or management
Confusing marketing, denial, disclosure, fees, closure, account access, interest, statements, joint
accounts
Deposits and withdrawals
Availability of deposits, withdrawal problems and penalties, unauthorized transactions, check
cashing, payroll deposit problems, lost or missing funds, transaction holds
Using a debit or ATM card
Disputed transaction, unauthorized card use, ATM or debit card fees, ATM problems
Making or receiving payments
Problems with payments by check, card, phone or online, unauthorized or fraudulent transactions
Problems caused by my funds being low
Overdraft fees, late fees, bounced checks

Form trouble?
Chat now.

Continue
Privacy act statement

OMB #3170-0011

File a bank account or service complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

2. Desired
resolution

3. My
information

4. Product
information

5. Review

This is the desired resolution

3870 characters remaining

Continue
Privacy act statement

Back
OMB #3170-0011

Form trouble?
Chat now.

File a bank account or service complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

✓ Desired
resolution

3. My
information

4. Product
information

5. Review

Myself

Someone else

Submitting on behalf of someone else may require signed, written permission.

My contact information
Dr
First name
name *
Last name
name *
V
Mailing
Mailing address
address*
Apartment,
Apartment, suite,
suite,building
building(Optional)
(Optional)
City *
State *
Zip
ZIP code
Code*
United States
Phone
Phone (Optional)
(Optional)
Email *
Account Holder's age is

(Optional)

The consumer is a servicemember or is a spouse or dependent of a servicemember. (Optional)

Form trouble?
Chat now.

Continue
Privacy act statement

Back
OMB #3170-0011

File a bank account or service complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

✓ Desired
resolution

✓ My
information

4. Product
information

5. Review

Billing address same as mailing
address.

Billing address
Billing
Billing address
address*
Apartment,
Apartment, suite,
suite,building
building(Optional)
(Optional)
City *
State *
Zip
ZIP code
Code*
United States

Account
Account number
number(Optional)
(Optional)
For account identification only

Information about the company
Company
Company name
Name*
The company name you entered is not in our database.
Please enter in the optional address information.

Company
Company address
Address(Optional)
(Optional)
City (Optional)
(Optional)
State (Optional)
Zip
ZIP code
Code(Optional)
United States
Do not submit a complaint if you do not want it to be forwarded to the company you select. All
complaints submitted on this site will be sent to the company for response.

Form trouble?
Chat now.

Upload any supporting documents (Optional)
Monthly statements, account agreements, power of attorney forms, CD certificates, etc.

Attach documents
Attach

Continue
Privacy act statement

Back
OMB #3170-0011

File a bank account or service complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

✓ Desired
resolution

✓ My
information

✓ Product
information

Form trouble?
Chat now.

WHAT HAPPENED [EDIT]
Describe what happened so we can understand the issue...
This is the what happened field
Consent to Publish? Consent provided
Product Checking account
Issue Account opening, closing, or management

DESIRED RESOLUTION [EDIT]
What do you think would be a fair resolution to your issue?
This is the desired resolution

MY INFORMATION [EDIT]
Contact information
Mailing address
Dr First name Last name V
Mailing address
Apartment, suite, building (Optional)
City DC Zip Code
United States
Email [email protected]
Phone Phone (Optional)
Age 50
I am submitting on behalf of

5. Review

Myself

Age 50

PRODUCT INFORMATION [EDIT]
Billing address is the same as mailing address.

Account number *************************
Information about the company
Company Name
Company Address (Optional)
City (Optional) Zip Code

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.

Submit

Privacy act statement

OMB #3170-0011

File a student loan complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

1. What
happened?

2. Desired
resolution

3. My
information

4. Product
information

5. Review

Form trouble?
Chat now.

My loan is *
Federal loan (Stafford, Direct, consolidation, PLUS, Perkins)
Non-federal loan (Private, alternative, other student loan)
I am not sure
Describe what happened so we can understand the issue. Include the name and location of your
school. *
Do not include sensitive information like your name, contact information, account number, or social
security number in this field. We will collect certain personal information at a later step.

This is the what happened field

Which of these best describes your issue? *
Getting a loan
Denial, confusing advertising or marketing, sales tactics or pressure, financial aid services,
recruiting, fraudulent loan
Can't qualify for a loan
Qualify for a better loan than the one offered
Can't repay my loan
Deferment, forbearance, default, bankruptcy, payment plan, refinancing

Dealing with my lender or servicer
Making payments, getting information about my loan, managing my account

Continue
Privacy act statement

OMB #3170-0011

File a student loan complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

2. Desired
resolution

3. My
information

4. Product
information

5. Review

This is the desired resolution field

3864 characters remaining

Continue
Privacy act statement

Back
OMB #3170-0011

Form trouble?
Chat now.

File a student loan complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

✓ Desired
resolution

3. My
information

4. Product
information

5. Review

Myself

Someone else

Submitting on behalf of someone else may require signed, written permission.

My contact information
Salutation (Optional)
First name
name *
Last name
name *
Suffix (Optional)
Mailing
Mailing address
address*
Apartment,
Apartment, suite,
suite,building
building(Optional)
(Optional)
City *
State *
Zip
ZIP code
Code*
United States
Phone
Phone (Optional)
(Optional)
Email *
Account Holder's age is

(Optional)

The consumer is a servicemember or is a spouse or dependent of a servicemember. (Optional)

Form trouble?
Chat now.

Continue
Privacy act statement

Back
OMB #3170-0011

File a student loan complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

✓ Desired
resolution

✓ My
information

4. Product
information

5. Review

Billing address same as mailing
address.

Billing address
Billing
Billing address
Address*
Apartment,
Apartment, suite,
suite,building
building(Optional)
(Optional)
City *
State *
Zip
ZIP code
Code*
United States

Account/Loan
Account/Loan number
numberororSSN
SSN
(Optional)
(Opt)
For account identification only

Information about the company
Company
Company name
Name*
The company name you entered is not in our database.
Please enter in the optional address information.

Company
Company address
address(Optional)
(Optional)
City (Optional)
(Optional)
State (Optional)
Zip
ZIP code
Code(Optional)
United States
Do not submit a complaint if you do not want it to be forwarded to the company you select. All
complaints submitted on this site will be sent to the company for response.

Form trouble?
Chat now.

Upload any supporting documents (Optional)
Account agreements, monthly statements, proof of payment, etc.

Attach documents
Attach

Continue
Privacy act statement

Back
OMB #3170-0011

File a student loan complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

✓ Desired
resolution

✓ My
information

✓ Product
information

Form trouble?
Chat now.

WHAT HAPPENED [EDIT]
Describe what happened so we can understand the issue...
This is the what happened field
Consent to Publish? Consent provided
Product Non-federal loan (Private, alternative, other student loan)
Issue Getting a loan: Can't qualify for a loan

DESIRED RESOLUTION [EDIT]
What do you think would be a fair resolution to your issue?
This is the desired resolution field

MY INFORMATION [EDIT]
Contact information
Mailing address
First name Last name
Mailing address
Apartment, suite, building (Optional)
City DC Zip Code
United States
Email [email protected]
Phone Phone (Optional)
I am submitting on behalf of

5. Review

Myself

PRODUCT INFORMATION [EDIT]
Billing address
Billing address
Apartment, suite, building (Optional)
City DC Zip Code
United States

Account/Loan number or SSN ********************************
Information about the company
Company Name
Company Address (Optional)
City (Optional)

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.

Submit

Privacy act statement

OMB #3170-0011

File a vehicle loan or consumer loan complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

1. What
happened?

2. Desired
resolution

3. My
information

4. Product
information

5. Review

This is the what happened field

My loan is a(n) *
Vehicle loan
Which of these best describes your issue? *
Problems when you are unable to pay
Repossession, deficiency, bankruptcy, default
Shopping for a loan or lease
Sales tactics or pressure, credit denial, confusing advertising or marketing
Taking out the loan or lease
Term changes (mid-deal changes, changes after closing, etc.), required add-on products, trade-in
payoff, fraud
Managing the loan or lease
Billing, late fees, damage or loss, insurance (GAP, credit, etc.), privacy

Form trouble?
Chat now.

Continue
Privacy act statement

OMB #3170-0011

File a vehicle loan or consumer loan complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

2. Desired
resolution

3. My
information

4. Product
information

5. Review

This is the desired resolution field

3864 characters remaining

Continue
Privacy act statement

Back
OMB #3170-0011

Form trouble?
Chat now.

File a vehicle loan or consumer loan complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

✓ Desired
resolution

3. My
information

4. Product
information

5. Review

Myself

Someone else

Submitting on behalf of someone else may require signed, written permission.

My contact information
Salutation (Optional)
First name
name *
Last name
name *
Suffix (Optional)
Mailing
Mailing address
address*
Apartment, suite, building (Optional)

City *
State *
Zip
ZIP code
Code*
United States
Phone
Phone (Optional)
(Optional)
Email *
Account Holder's age is

(Optional)

The consumer is a servicemember or is a spouse or dependent of a servicemember. (Optional)

Form trouble?
Chat now.

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Privacy act statement

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OMB #3170-0011

File a vehicle loan or consumer loan complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

✓ Desired
resolution

✓ My
information

4. Product
information

5. Review

Billing address same as mailing
address.

Billing address
Billing
Billing address
address*
Apartment,
Apartment, suite,
suite,building
building(Optional)
(Optional)
City *
State *
Zip
ZIP code
Code*
United States

Account/Loan
Account/Loan number
number(Optional)
(Optional)
For account identification only

Information about the company
Company
Company name
Name*
The company name you entered is not in our database.
Please enter in the optional address information.

Form trouble?
Chat now.

Upload any supporting documents (Optional)
Account agreements, monthly statements, proof of payment, etc.

Attach documents
Attach

Continue
Privacy act statement

Back
OMB #3170-0011

File a vehicle loan or consumer loan complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

✓ Desired
resolution

✓ My
information

✓ Product
information

Form trouble?
Chat now.

WHAT HAPPENED [EDIT]
Describe what happened so we can understand the issue...
This is the what happened field
Consent to Publish? Consent provided
Product Vehicle loan
Issue Shopping for a loan or lease

DESIRED RESOLUTION [EDIT]
What do you think would be a fair resolution to your issue?
This is the desired resolution field

MY INFORMATION [EDIT]
Contact information
Mailing address
First name Last name
Mailing address
City DC Zip Code
United States
Email [email protected]
Phone Phone (Optional)
Age 50
I am submitting on behalf of

Myself

Age 50

PRODUCT INFORMATION [EDIT]
Account number ******************************
Information about the company

5. Review

Company Name
Company Address (Optional)
City (Optional) Zip Code

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.

Submit

Privacy act statement

OMB #3170-0011

File a credit reporting complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

1. What
happened?

2. Product
information

3. Desired
resolution

4. Consumer
information

5. Review

Which of these best describes your issue? *
Incorrect information on my credit report
Information is not mine
Belongs to someone else, identity theft, fraud, etc.
Account terms
Creditor name/info, balance, payment, etc.
Account status
Paid bill on time, account closed, etc.
Personal information
Wrong date of birth, address, etc.
Public record
Bankruptcy, judgment, etc.
Reinserted previously deleted information
Credit Reporting company's investigation
Improper use of my credit report
Unable to get my credit report or credit score
Credit monitoring or identity protection services

Have you disputed the issue with the credit reporting company and
received a final response?
Yes

Original dispute case number (Optional)

Form trouble?
Chat now.

Describe what happened so we can understand the issue. *
Do not include sensitive information like your name, contact information, account number, or social
security number in this field. We will collect certain personal information at a later step.

This is the what happened field

Upload any supporting documents (Optional)
Incorrect part of credit reports, payment records, cancelled checks, court documents, birth
certificates or other identity verification documents, copy of credit reporting company's investigation

Attach documents
Attach

Continue
Privacy act statement

OMB #3170-0011

File a credit reporting complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

2. Product
information

3. Desired
resolution

4. Consumer
information

5. Review

Information about the credit reporting company
Company
Company name
Name*
The company name you entered is not listed in our database as a credit reporting company.
Please enter the optional address information.

Company
Company address
Address(Optional)
City (Optional)
State (Optional)
Zip
ZIP code
Code(Optional)
United States
Do not submit a complaint if you do not want it to be forwarded to the company you select. All
complaints submitted on this site will be sent to the company for response.

Account identification information
We need this information to make sure the credit reporting company is able to find your file. Without
it, we may not be able to help.
Social Security number (Optional)
Date of birth (Optional)
Name on credit report (Optional)

XXX-XX-XXXX
MM/DD/YYYY
First middle last

Continue

Back

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Privacy act statement

OMB #3170-0011

File a credit reporting complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

✓ Product
information

3. Desired
resolution

4. Consumer
information

5. Review

This is the desired resolution field

3864 characters remaining

Continue
Privacy act statement

Back
OMB #3170-0011

Form trouble?
Chat now.

File a credit reporting complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

✓ Product
information

✓ Desired
resolution

4. Consumer
information

5. Review

Select "Someone else" if assisting someone in submitting a complaint. Provide your information
under "My contact information" and the other person’s information under "Someone else".
I am submitting on behalf of

Myself

Someone else

Submitting on behalf of someone else may require signed, written permission.

My contact information
Salutation (Optional)
First name
Name*
Middle
Middlename
Name
(Optional)
(Optional)

Last name
Name*
Suffix (Optional)
Mailing
Mailing address
Address*
Apartment,
Apartment, suite,
suite,building
building(Optional)
(Optional)
City *
State *
Zip
ZIP code
Code*
United States
Phone
Phone (Optional)
(Optional)
Email *
Account Holder's age is

(Optional)

Form trouble?
Chat now.

The consumer is a servicemember or is a spouse or dependent of a servicemember. (Optional)

Continue
Privacy act statement

Back
OMB #3170-0011

File a credit reporting complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

✓ Product
information

✓ Desired
resolution

✓ Consumer
information

5. Review

Form trouble?
Chat now.

WHAT HAPPENED [EDIT]
Issue Incorrect information on my credit report: Information is not mine
Describe what happened so we can understand the issue...
This is the what happened field
Consent to Publish? Consent provided

PRODUCT INFORMATION [EDIT]
Information about the credit reporting company
Company Name
Company Address
City Zip Code

DESIRED RESOLUTION [EDIT]
What do you think would be a fair resolution to your issue?
This is the desired resolution field

CONSUMER INFORMATION [EDIT]
Contact information
Mailing address
First Name Middle Name (Optional) Last Name
Mailing Address
Apartment, suite, building (Optional)
City DC Zip Code
United States
Email [email protected]
Phone Phone (Optional)
I am submitting on behalf of

Myself

I authorize and direct any consumer reporting agency to furnish a copy of my consumer report to
the CFPB for the purpose of responding to and investigating my consumer complaint.
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.

Submit

Privacy act statement

OMB #3170-0011

File a money transfer complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

1. What
happened?

2. Desired
resolution

3. My
information

4. Product
information

5. Review

This is the what happened field

This is about a(n) *
Domestic (US) money transfer
Which of these best describes your issue? *
Money was not available when promised
Wrong amount charged or received
Transfer amounts, fees, exchange rates, taxes, etc.
Incorrect/missing disclosures or info
Other transaction issues
Unauthorized transaction, cancellation, refund, etc.
Other service issues
Advertising or marketing, pricing, privacy, etc.
Fraud or scam

Form trouble?
Chat now.

Continue
Privacy act statement

OMB #3170-0011

File a money transfer complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

2. Desired
resolution

3. My
information

4. Product
information

5. Review

This is the desired resolution

3870 characters remaining

Continue
Privacy act statement

Back
OMB #3170-0011

Form trouble?
Chat now.

File a money transfer complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

✓ Desired
resolution

3. My
information

4. Product
information

5. Review

Submitting on behalf of someone else may require signed, written permission.
I am (the)

Sender

Recipient

Filing on behalf of someone else

Myself

My contact information
Salutation (Optional)
First name
name *
Middle
Middlename
name(Optional)
(Optional)

Last name
name *
Suffix (Optional)
United States
Mailing
Mailing address
address*
Apartment,
Apartment, suite,
suite,building
building(Optional)
(Optional)
City *
State *
Zip
ZIP code
Code*
Phone
Phone (Optional)
(Optional)
Email *
Account Holder's age is

(Optional)

Someone else

Form trouble?
Chat now.

Submitting on behalf of someone else may require signed, written permission.

The consumer is a servicemember or is a spouse or dependent of a servicemember. (Optional)

Continue
Privacy act statement

Back
OMB #3170-0011

File a money transfer complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

✓ Desired
resolution

✓ My
information

4. Product
information

5. Review

What company was used to send the money?
Company name on the receipt

Company
Company name
name*
The company name you entered is not in our database.
Please enter in the optional address information.

Account
Account number
number(Optional)
(Optional)
Account number associated with the company used for this transfer
Where did the transaction take place? (Optional)

Online
Website
Website or
orname
nameofofmobile
mobileapp
app
(Optional)
(Optional)
Sender Information
Salutation (Optional)
First name
name *
Middle
Middle name
name(Optional)
(Optional)
Last name
name *
Suffix (Optional)

Form trouble?
Chat now.

United States
Mailing
Mailing address
address(Optional)
(Optional)
Apartment,
Apartment, suite,
suite,building
building(Optional)
(Optional)
City (Optional)
(Optional)
State *
Zip
ZIP code
code (Optional)
Phone
Phone (Optional)
(Optional)
Email (Optional)
(Optional)
How much was transferred? (Optional)

USD United States Dollar

0.00
Amount must be in 0.00 format

Date of transfer (Optional)
When money was sent

3/1/2015
What is the transfer ID or transaction number? (Optional)
Transaction number or transfer ID may be found on money transfer receipt

ID or number
number
Funds promised date (Optional)
When funds expected

3/31/2015
Amount of error (Optional)

USD United States Dollar

0.00
Amount must be in 0.00 format

Date issue occurred (Optional)
When error was found

3/1/2015
Person receiving funds
How was the transfer received? (Optional)

Deposited or credited to an account
Company
Company name
name*
United States

Company
Company address
address(Optional)
(Optional)
City (Optional)
(Optional)
State *
Zip
ZIP code
code (Optional)
Website
Website or
orname
nameofofmobile
mobileapp
app
(Optional)
(Optional)
Account
Account number
number(Optional)
(Optional)
Account number associated with the company that received this transfer

Salutation (Optional)
First name
name *
Middle
Middle name
name(Optional)
(Optional)
Last name
name *
Suffix (Optional)
United States
Mailing
Mailing address
address(Optional)
(Optional)
Apartment,
Apartment, suite,
suite,building
building(Optional)
(Optional)
City (Optional)
(Optional)
State *
Zip
ZIP code
Code(Optional)
Phone
Phone (Optional)
(Optional)
Email (Optional)
(Optional)

Upload any supporting documents (Optional)
Copies of receipts, disclosures provided for transaction, account statements,
advertisements/marketing letters, etc.

Attach documents
Attach

Continue
Privacy act statement

Back
OMB #3170-0011

File a money transfer complaint
We'll forward your issue to the company, give you a tracking number, and keep you updated on the
status of your complaint.

✓ What
happened?

✓ Desired
resolution

✓ My
information

✓ Product
information

5. Review

Form trouble?
Chat now.

WHAT HAPPENED [EDIT]
Describe what happened so we can understand the issue...
This is the what happened field
Consent to Publish? Consent provided
This is about a(n) Domestic (US) money transfer
Which of these best describes your issue? Money was not available when promised

DESIRED RESOLUTION [EDIT]
What do you think would be a fair resolution to your issue?
This is the desired resolution field

CONSUMER INFORMATION [EDIT]
Contact information
Mailing address
First name Middle name (Optional) Last name
Mailing address
Apartment, suite, building (Optional)
City DC Zip Code
United States
Email [email protected]
Phone Phone (Optional)
I am submitting on behalf of

Myself

PRODUCT INFORMATION [EDIT]
What company was used to send the money?
Company name
Company Address
City Zip Code

Account number Account number (Optional)
Where did the transaction take place? Online
Website or name of mobile app Website or name of mobile app (Optional)

Sender Information
First name Middle name (Optional) Last name
Mailing address (Optional)
Apartment, suite, building (Optional)
City (Optional) DC Zip code
United States
Phone (Optional)
[email protected]
How much was transferred? 0.00 USD United States Dollar
Date of transfer 3/1/2015
What is the transfer ID or transaction number? ID or number
Funds promised date 3/31/2015
Amount of error 0.00 USD United States Dollar
Date issue occurred 3/1/2015

Person receiving funds
How was the transfer received? Deposited or credited to an account
Company name
Company address (Optional)
City (Optional) DC Zip code
United States
Website or name of mobile app (Optional)
Account number (Optional)
First name Middle name (Optional) Last name
Mailing address (Optional)
Apartment, suite, building (Optional)
City (Optional) DC Zip Code
United States
Phone (Optional)
[email protected]

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.

Submit

Privacy act statement

OMB #3170-0011

An official website of the United States Government

Submit a debt collection complaint

WHAT HAPPENED?
COMPANY INFORMATION

What happened
What type of debt
is this?

Incomplete

MY INFORMATION
Incomplete

Why do we need this?
Credit card

Mortgage

Medical

Payday loan

Auto

Other (i.e. phone, health club, etc.)

Federal student loan

I do not know

Non-federal student loan

REVIEW AND SUBMIT
Incomplete

Form trouble? Chat now.

Which of these
best describes
your issue?

Communication tactics

Frequent or repeated calls
Called outside of 8am-9pm
Used obscene, profane or other abusive language
Threatened to take legal action
Called after sent written cease of communication notice

What phone
number are they
calling?
(Optional)

Describe what
happened so we
can understand
the issue...

This is the what happened field

3869 characters remaining

Do not include sensitive information like your name, contact information,
account number, or social security number in this field. We will collect
certain personal information at a later step.
I want the CFPB to publish this description on consumerfinance.gov so
that others can learn from my experience with this company. I understand
that there is a small chance that someone may be able to identify me based
on the information I've included. Learn more

Desired resolution
What do you think
would be a fair
resolution to your
issue?

Why do we need this?
This is the desired resolution field

3864 characters remaining

Do not include sensitive information like your name, contact information,
account number, or social security number in this field. We will collect
certain personal information at a later step.

CONTINUE

Privacy act statement | OMB #3170-0011
Have questions? Need help with this form? (855) 411-2372

An official website of the United States government

An official website of the United States Government

Submit a debt collection complaint

Who's contacting you about this debt?
Debt collection
company name:

Why do we need this?
I do not know the
debt collection
company name

Company Name

Address:
(Optional)

Country:
(Optional)

Zip code:

Choose...

(Optional)

State:

City:

Choose...

(Optional)

Phone number:

Add another number

(Optional)

Representative
name or ID:
(Optional)

Account number:
(Optional)

Do you know where this debt came from?
Do you know
where this debt
came from?
Company name:

Address:
(Optional)

Address 2:

WHAT HAPPENED?

(Optional)

Same company

Company Name

Why do we need this?

A different company

I don't know

I do not know the
company name

COMPANY INFORMATION

Country:
(Optional)

Zip:

Choose...

(Optional)

MY INFORMATION
Incomplete

State:

City:

REVIEW AND SUBMIT

Choose...

(Optional)

Incomplete

Phone number:

Form trouble? Chat now.

Add another number

(Optional)

Representative
name or ID:
(Optional)

Account number:
(Optional)

Submit a separate
complaint against
this company?

Yes

Upload any supporting documents
Attach documents
(Optional)

Why do we need this?

SELECT FILE
We accept all file formats except executable files (.exe)

CONTINUE

Privacy act statement | OMB #3170-0011
Have questions? Need help with this form? (855) 411-2372

An official website of the United States government

An official website of the United States Government

Submit a debt collection complaint

WHAT HAPPENED?

Personal information
Salutation

COMPANY INFORMATION
MY INFORMATION
Incomplete

Why do we need this?
Choose...

(Optional)

Middle:

First Name:

(Optional)

REVIEW AND SUBMIT
Incomplete

Suffix:

Last Name:

(Optional)

Form trouble? Chat now.

Last four digits of
Social Security
Number:
(Optional)

Choose...

Companies match this information to their records to respond to your
complaint. Not providing may delay or prevent the company from responding
to your complaint.

Age:
(Optional)

Contact information

Why do we need this?

Address:

Address 2:
(Optional)

Country:

City:

Phone Number:
(Optional)

Email:

United States

Zip code:

State:

Choose...

Military affiliation
The consumer is
now or was:

Why do we need this?
A
servicemember

(Optional)
(Choose all that apply)

The dependent or spouse of a
servicemember

Please enter the servicemember information below.

Salutation:
(Optional)

Choose...

Middle

First Name:

(Optional)

Suffix:

Last Name:

(Optional)

Choose...

Address:

Address 2:

Country:

Choose...

City:

Status:

Choose...

Rank:

Choose...

Zip code:

State:

Choose...

Branch:

Choose...

CONTINUE

Privacy act statement | OMB #3170-0011
Have questions? Need help with this form? (855) 411-2372

An official website of the United States government

An official website of the United States Government

Submit a debt collection complaint

Only the highlighted information below will be sent to these companies.

Review your information
WHAT HAPPENED?

Edit this section

What type of debt is this?
Credit card
Which of these best describes your issue?
Called outside of 8am-9pm
Describe what happened so we can understand the issue...
This is the what happened field
Consent to Publish?
Consent provided

WHAT HAPPENED?
What do you think would be a fair resolution to your issue?

COMPANY INFORMATION

MY INFORMATION
REVIEW AND SUBMIT
Incomplete

This is the desired resolution field

COMPANY INFORMATION

Edit this section

Debt collection company
Company Name

Form trouble? Chat now.

Do you know where this debt came from?
A different company
Original creditor
Company Name

MY INFORMATION

Edit this section

Your name

The last four digits of your SSN

First Name Last Name

SSN

Mailing address

Contact information

Address
City DC 20000
United States

[email protected]
Your age is
25

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.

SUBMIT

Privacy act statement | OMB #3170-0011
Have questions? Need help with this form? (855) 411-2372

An official website of the United States government

An official website of the United States Government

Submit a payday or other consumer loan complaint

WHAT HAPPENED?
Incomplete

If your complaint concerns lender collection practices on your loan, you
should submit a Debt Collection complaint.

MY INFORMATION
Incomplete

What happened

Why do we need this?

COMPANY INFORMATION
Incomplete

REVIEW AND SUBMIT

Which type of
loan is your
complaint about?

Installment loan
Loan paid in regular fixed payments, Rent-to-Own, appliances, medical, etc

Pawn loan

Incomplete

Loan secured by personal property

Title loan

Form trouble? Chat now.

Loan usually secured by a vehicle title

Payday loan
Short-term loan or cash advance

Which of these
best describes
your issue?

Charged fees or interest I didn't expect
Can't stop lender from charging my bank account
Received a loan I didn't apply for
Applied for a loan, but didn't receive money
Lender charged my bank account on wrong day or for wrong
amount
Lender didn't credit payment to my account
Can't contact lender
Lender repossessed or sold the vehicle
Lender damaged or destroyed vehicle

Describe what
happened so we
can understand
the issue...

This is the what happened field

3869 characters remaining

Do not include sensitive information like your name, contact information,
account number, or social security number in this field. We will collect
certain personal information at a later step.
I want the CFPB to publish this description on consumerfinance.gov so
that others can learn from my experience with this company. I understand
that there is a small chance that someone may be able to identify me
based on the information I've included. Learn more

Desired resolution
What do you think
would be a fair
resolution to your

Why do we need this?
This is the desired resolution field

resolution to your
issue?

3864 characters remaining

Do not include sensitive information like your name, contact information,
account number, or social security number in this field. We will collect
certain personal information at a later step.

CONTINUE

Privacy act statement | OMB #3170-0011
Have questions? Need help with this form? (855) 411-2372

An official website of the United States government

An official website of the United States Government

Submit a payday or other consumer loan complaint

WHAT HAPPENED?
MY INFORMATION
Incomplete

Who is the borrower?

Why do we need this?
I am the
borrower

Who is the
borrower of the
loan?

I am submitting on behalf of the
borrower

COMPANY INFORMATION
Incomplete

REVIEW AND SUBMIT
Incomplete

What is your
relationship to the
borrower?

Housing counselor

Form trouble? Chat now.

Borrower information
Salutation
(Optional)

First name

Last name

Address

Why do we need this?

Choose...

First name

Last name

Middle
(Optional)

Suffix
(Optional)

Choose...

Address

Address 2
(Optional)

Country

United States

Zip code

State

City

Choose...

Age
(Optional)

Your information
Salutation
(Optional)

First name

Why do we need this?
Choose...

Middle
(Optional)

Last name

Suffix
(Optional)

Address

Choose...

Address 2
(Optional)

Country

United States

Zip code

State

City

Choose...

Phone number
(Optional)

If you enter your email
address here, the CFPB will
send you all further
communications by email.

Military affiliation
The borrower is
(Optional)
(Choose all that apply)

Why do we need this?
A servicemember or
veteran
The spouse or dependent of a servicemember or
veteran

Current status

Choose...

Rank

Choose...

Branch

Choose...

CONTINUE

Privacy act statement | OMB #3170-0011
Have questions? Need help with this form? (855) 411-2372

An official website of the United States government

An official website of the United States Government

Submit a payday or other consumer loan complaint

WHAT HAPPENED?

Loan details
Where did you
get the loan?

MY INFORMATION

(Optional)

In which state is
the store located?

COMPANY INFORMATION

Why do we need this?
In person / at a store

(even if you applied online)

Online

Choose...

(Optional)

This is important because
different states have
different lending laws.

REVIEW AND SUBMIT
Incomplete

Loan number
(Optional)

Form trouble? Chat now.

Company details
Company name

Why do we need this?
Company Name

Address
(Optional)

Country
(Optional)

United States

Zip code
(Optional)

City

State

(Optional)

Upload any supporting documents
Attach documents
(Optional)

Choose...

Why do we need this?

SELECT FILE
We accept all file formats except executable files (.exe)

CONTINUE

Privacy act statement | OMB #3170-0011
Have questions? Need help with this form? (855) 411-2372

An official website of the United States government

An official website of the United States Government

Submit a payday or other consumer loan complaint

WHAT HAPPENED?

MY INFORMATION

Please review your information below before submitting.
You can return to any section to make changes by clicking 'Edit this
section'.

COMPANY INFORMATION
REVIEW AND SUBMIT
Incomplete

Form trouble? Chat now.

Edit this section

WHAT HAPPENED
Which type of loan
is your complaint
about?

Which of these
best describes
your issue?

Describe what
happened so we
can understand
the issue...
Consent to
Publish?

What do you think
would be a fair
resolution to your
issue?

Title loan

Can't contact lender

This is the what happened field

Consent not provided

This is the desired resolution field

Edit this section

MY INFORMATION
Your name

Address

First Name Last Name

Address
City DC 20000
United States
[email protected]

Phone
(Optional)

Who is the
borrower of the
loan?

I am the borrower

loan?

Age
(Optional)

Edit this section

COMPANY INFORMATION
Where did you get
the loan?
(Optional)

Loan company

In person / at a store
District Of Columbia

Company Name
United States

Loan number
(Optional)

Supporting
documents
(Optional)

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.

SUBMIT

Privacy act statement | OMB #3170-0011
Have questions? Need help with this form? (855) 411-2372

An official website of the United States government

An official website of the United States Government

Submit a prepaid card complaint

WHAT HAPPENED?
MY INFORMATION
Incomplete

What happened
Which of these
best describes
your issue?

Why do we need this?
Managing, opening, or closing your account
Fees
Unauthorized transactions or other transaction issues

COMPANY INFORMATION

Advertising, marketing or disclosures

Incomplete

Adding money

REVIEW AND SUBMIT
Incomplete

Overdraft, savings or rewards features
Fraud or scam

Form trouble? Chat now.
Describe what
happened so we
can understand
the issue...

This is the what happened field

3869 characters remaining

Do not include sensitive information like your name, contact information,
account number, or social security number in this field. We will collect
certain personal information at a later step.
I want the CFPB to publish this description on consumerfinance.gov so
that others can learn from my experience with this company. I understand
that there is a small chance that someone may be able to identify me
based on the information I've included. Learn more

Desired resolution
What do you think
would be a fair
resolution to your
issue?

Why do we need this?
This is the desired resolution field

3864 characters remaining

Do not include sensitive information like your name, contact information,
account number, or social security number in this field. We will collect
certain personal information at a later step.

CONTINUE

Privacy act statement | OMB #3170-0011
Have questions? Need help with this form? (855) 411-2372

An official website of the United States government

An official website of the United States Government

Submit a prepaid card complaint

WHAT HAPPENED?
MY INFORMATION

Who is the cardholder?
Who is the
cardholder?

Incomplete

Why do we need this?

I am the
cardholder
I am submitting on behalf of the
cardholder

COMPANY INFORMATION
Incomplete

REVIEW AND SUBMIT
Incomplete

Form trouble? Chat now.

Your information
Salutation
(Optional)

Why do we need this?
Choose...

Middle

First name

(Optional)

Suffix

Last name

(Optional)

Choose...

Address

Address 2
(Optional)

Country

United States

Zip code

State

City

Choose...

If you enter your email
address here, the CFPB will
send you all further
communications by email.

Phone number
(Optional)

Age
(Optional)

Military affiliation
I am
(Optional)
(Choose all that apply)

Why do we need this?
A servicemember or
veteran
The spouse or dependent of a servicemember or
veteran

CONTINUE

Privacy act statement | OMB #3170-0011
Have questions? Need help with this form? (855) 411-2372

An official website of the United States government

An official website of the United States Government

Submit a prepaid card complaint

Card details
Which type of
card is your
complaint about?

Why do we need this?
Government benefit payment card
Used for receiving Social Security, unemployment compensation or a tax refund

Electronic Benefit Transfer / EBT card
Used for receiving welfare payments like WIC,TANF, & SNAP

ID prepaid card
Prepaid card attached to a student or other ID

WHAT HAPPENED?

Transit card
A transit card used for shopping anywhere

MY INFORMATION

Gift or merchant card
Gift, loyalty or promotional card isued by a store

General purpose card

COMPANY INFORMATION

Used for shopping anywhere

Mobile wallet

REVIEW AND SUBMIT

Money held in a mobile, online or virtual account

Incomplete

Payroll card
Used for receiving your paycheck from your employer

Form trouble? Chat now.

Other special purpose card
Used for health care, insurance, rebates, phone or disaster assistance

Company details
Company name

Why do we need this?
Company Name

Address
(Optional)

Country
(Optional)

United States

Zip code
(Optional)

City

State

(Optional)

Choose...

Phone number
(Optional)

Upload any supporting documents
Attach documents
(Optional)

Why do we need this?

SELECT FILE
We accept all file formats except executable files (.exe)

CONTINUE

Privacy act statement | OMB #3170-0011
Have questions? Need help with this form? (855) 411-2372

An official website of the United States government

An official website of the United States Government

Submit a prepaid card complaint

WHAT HAPPENED?

MY INFORMATION

Please review your information below before submitting.
You can return to any section to make changes by clicking 'Edit this
section'.

COMPANY INFORMATION
REVIEW AND SUBMIT
Incomplete

Form trouble? Chat now.

Edit this section

WHAT HAPPENED
Which of these
best describes
your issue?

Describe what
happened so we
can understand
the issue...
Consent to
Publish?

What do you think
would be a fair
resolution to your
issue?

Fees

This is the what happened field

Consent not provided

This is the desired resolution field

Edit this section

MY INFORMATION
Your name

Address

First Name Last Name

Address
City DC 20000
United States
[email protected]

Phone
(Optional)

Who is the
cardholder?

Age
(Optional)

I am the cardholder

Edit this section

COMPANY INFORMATION
Which type of card
is your complaint
about?

Prepaid card
company

General purpose card

Company Name
United States

Supporting
documents
(Optional)

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.

SUBMIT

Privacy act statement | OMB #3170-0011
Have questions? Need help with this form? (855) 411-2372

An official website of the United States government

An official website of the United States Government

Submit an other financial service complaint

What happened
WHAT HAPPENED?

Which type of
service is your
complaint about?

Why do we need this?
Check cashing
A store that cashes a check for a fee

Credit repair
Services for improving your credit report

MY INFORMATION
Incomplete

Debt settlement
Services for reducing your debt balance

COMPANY INFORMATION

Foreign currency exchange

Incomplete

Transactions that convert money between currencies

Money order

REVIEW AND SUBMIT

A prepaid check for a set amount of money

Incomplete

Refund anticipation check
A check paid to you by a bank or company with your expected tax refund

Form trouble? Chat now.

Traveler’s/Cashier’s checks
A check with secured funds from a bank or other financial institution

Which of these
best describes
your issue?

Advertising and marketing
Customer service/Customer relations
Disclosures
Excessive fees
Unexpected/Other fees
Incorrect exchange rate
Fraud or scam

Describe what
happened so we
can understand
the issue...

This is the what happened field

3869 characters remaining

Do not include sensitive information like your name, contact information,
account number, or social security number in this field. We will collect
certain personal information at a later step.
I want the CFPB to publish this description on consumerfinance.gov so
that others can learn from my experience with this company. I understand
that there is a small chance that someone may be able to identify me
based on the information I've included. Learn more

Desired resolution
What do you think
would be a fair
resolution to your
issue?

Why do we need this?
This is the desired resolution field

3864 characters remaining

Do not include sensitive information like your name, contact information,
account number, or social security number in this field. We will collect
certain personal information at a later step.

CONTINUE

Privacy act statement | OMB #3170-0011
Have questions? Need help with this form? (855) 411-2372

An official website of the United States government

An official website of the United States Government

Submit an other financial service complaint

WHAT HAPPENED?
MY INFORMATION

Who received this service
Who received this
service?

Incomplete

Why do we need this?

I received this
service
I am submitting on behalf of the person who received this
service

COMPANY INFORMATION
Incomplete

REVIEW AND SUBMIT
Incomplete

Form trouble? Chat now.

Your information
Salutation
(Optional)

Why do we need this?
Choose...

Middle

First name

(Optional)

Suffix

Last name

(Optional)

Choose...

Address

Address 2
(Optional)

Country

United States

Zip code

State

City

Choose...
If you enter your email
address here, the CFPB will
send you all further
communications by email.

Phone number
(Optional)

Age
(Optional)

Military affiliation
I am
(Optional)
(Choose all that apply)

Why do we need this?
A servicemember or
veteran
The spouse or dependent of a servicemember or
veteran

CONTINUE

Privacy act statement | OMB #3170-0011
Have questions? Need help with this form? (855) 411-2372

An official website of the United States government

An official website of the United States Government

Submit an other financial service complaint

WHAT HAPPENED?

Company details
Company name

Why do we need this?
Company Name

MY INFORMATION
Address
(Optional)

COMPANY INFORMATION

Country
(Optional)

REVIEW AND SUBMIT
Incomplete

Form trouble? Chat now.

United States

Zip code
(Optional)

City

State

(Optional)

Choose...

Phone number
(Optional)

Upload any supporting documents
Attach documents
(Optional)

Why do we need this?

SELECT FILE
We accept all file formats except executable files (.exe)

CONTINUE

Privacy act statement | OMB #3170-0011
Have questions? Need help with this form? (855) 411-2372

An official website of the United States government

An official website of the United States Government

Submit an other financial service complaint

WHAT HAPPENED?

MY INFORMATION

Please review your information below before submitting.
You can return to any section to make changes by clicking 'Edit this
section'.

COMPANY INFORMATION
REVIEW AND SUBMIT
Incomplete

Form trouble? Chat now.

Edit this section

WHAT HAPPENED
Which type of
service is your
complaint about?

Which of these
best describes
your issue?

Describe what
happened so we
can understand
the issue...
Consent to
Publish?

What do you think
would be a fair
resolution to your
issue?

Foreign currency exchange

Disclosures

This is the what happened field

Consent not provided

This is the desired resolution field

Edit this section

MY INFORMATION
Your name

Address

First Name Last Name

Address
City DC 20000
United States
[email protected]

Phone
(Optional)

Who received the
service?

I received the service

Age
(Optional)

Edit this section

COMPANY INFORMATION
Financial service
company

Company Name
United States

Supporting
documents
(Optional)

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.

SUBMIT

Privacy act statement | OMB #3170-0011
Have questions? Need help with this form? (855) 411-2372

An official website of the United States government

Password

Username

Password

Forgot your password?

This is a Consumer Financial Protection Bureau (CFPB)
information system. The CFPB is an independent agency of the
United States Government. CFPB information systems are
provided for the processing of official information only.
Unauthorized or improper use of this system may result in
administrative action, as well as civil and criminal penalties.
Because this is a CFPB information system, you have no
reasonable expectation of privacy regarding any communication
or data transiting or stored on this information system. All data
contained on CFPB information systems is owned by CFPB and
your use of the CFPB information system serves as your consent
to your usage being monitored, intercepted, recorded, read,
copied, captured or otherwise audited in any manner, by
authorized personnel, including but not limited to employees,
contractors, and/or agents of the United States Government.

Tell your story
This is not a complaint form. Go here for complaints

Tell us your story, good or bad, about your experience with consumer financial products. Your story
will help inform how we work to protect consumers and create a fairer marketplace.
Describe what happened... *
Do not include sensitive information like your name, contact information, account number, or social
security number in this field. You can provide your contact information below.

This is what happened

Tag your
your issue
issue
Mortgage, credit card, student loan, etc.

Submit anonymously

Zip
ZIP code
Code
First name
name
Last name
name
Phone
Phone
Is this about something you saw while working for a financial company? *
Yes

Tell your story

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. 2 / 2015

SUBMIT A COMPLAINT ABOUT A FINANCIAL PRODUCT OR SERVICE

1 OF 7

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

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

When did this
happen?

YYYY

OPTIONAL

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

OPTIONAL

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

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

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

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

YYYY

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

OPTIONAL

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)

3 OF 7

4 OF 7

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

Account holder’s
information

FIRST NAME

FILL OUT QUESTIONS 13, 13A, 14 & 15

LAST NAME

SUFFIX

STREET

CITY

STATE

13a

Account
holder’s age

ZIP CODE

COUNTRY

PHONE NUMBER

AGE

OPTIONAL

Account number

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

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

7 OF 7

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)

Formulario de queja
SOBRE PRODUCTOS O SERVICIOS FINANCIEROS

Cómo presentar una queja
Por Internet (recomendado)
consumerfinance.gov/complaint

Por teléfono
(855) 411-CFPB (2372)

Por correo
Oficina para la Protección Financiera del Consumidor
PO Box 4503, Iowa City, IA 52244

Por fax
(855) 237-2392

Después de presentar una queja
Presentación
de la queja

Usted presenta una queja sobre un problema que tenga con una empresa
acerca de un producto o servicio financiero de consumo. Usted recibirá
actualizaciones por correo electrónico y podrá entrar al sistema para darle
seguimiento al estado de su queja.

Revisión y
proceso

Enviaremos su queja a la empresa y trabajaremos para obtener una respuesta.
Si consideramos que otra agencia del gobierno está en mejores condiciones de
ayudar, le enviaremos su queja a la misma y se lo informaremos.

Respuesta de
la empresa

La empresa revisará su queja, se comunicará con usted cuando sea necesario y le
informará Acerca de las medidas que se tomaron o que se tomarán en respuesta a
su queja. En estos momentos, nuestros informes están en inglés, pero nos puede
llamar al (855) 411-2372 para recibir ayuda de una persona que habla español.

Revisión del
consumidor

Le informaremos sobre la respuesta de la empresa cuando recibamos la misma.
Usted podrá revisar la respuesta y darnos su opinión.

Revisión e
investigación

Los datos de las quejas se comparten con las autoridades estatales y federales.
Las quejas nos informan sobre las prácticas comerciales que creen riesgos para
los consumidores ocasionar riesgos a los consumidores. Si necesitamos más
información, se lo haremos saber.

Análisis e
informe

Las quejas ayudan con nuestro trabajo para supervisar a las empresas, hacer
cumplir las leyes federales de protección al consumidor y redactar mejores
normas y reglamentos. Asimismo, informamos al Congreso acerca de las quejas
que recibimos y publicamos algunos datos de quejas de los consumidores.

NÚMERO DE QUEJA

¿NECESITA AY UDA CON ES TE FORMUL ARIO?
(855) 411- CFPB (2372)

VERSIÓN 3. 2 / 2015

FORMULARIO DE QUEJA SOBRE PRODUCTOS O SERVICIOS FINANCIEROS

1 DE 7

¿Qué pasó?
Queremos entender su situación para poder identificar con precisión el problema que dio lugar a su queja. Si usted
nos proporciona los detalles de lo ocurrido —como las fechas y lugares de las transacciones; entonces podremos
entender mejor su queja.
1

Describa lo que
pasó, para que
podamos entender
el problema.
No incluya aquí
ninguna de su
información de
contacto personal.
Le pediremos esta
información en un
paso posterior.

¿Cómo quiere que se resuelva su queja?
Queremos saber que piensa usted que sería una resolución justa del problema. Le enviaremos esta información a la
empresa, junto con su descripción de lo ocurrido, para que entiendan lo que usted busca.

¿Qué piensa usted
que sería una
resolución justa
del problema?
No incluya aquí
ninguna de su
información de
contacto personal.
Le pediremos esta
información en un
paso posterior.

NÚMERO DE QUEJA

¿NECESITA AY UDA CON ES TE FORMUL ARIO?
(855) 411- CFPB (2372)

2 DE 7

FORMULARIO DE QUEJA SOBRE PRODUCTOS O SERVICIOS FINANCIEROS

Tipo de producto o servicio
3

¿De qué se trata
esta queja?

Cuéntenos en pocas
palabras cuál fue el
problema con este
producto o servicio.

¿Cuándo ocurrió
esto?

HIPOTECA

TARJETA DE CRÉDITO

PRÉSTAMO DE AVANCE DE PAGO

INFORME DE CRÉDITO

TARJETA PREPAGADA

OTRO PRÉSTAMO DE CONSUMO

TRANSFERENCIA DE DINERO

PRÉSTAMO ESTUDIANTIL

OTRO SERVICIO FINANCIERO

VEHICULAR

ESCOJA UNO

PRÉSTAMO O ARRENDAMIENTO

CUENTA O SERVICIO BANCARIO

AAAA

OPCIONAL

Basándose en lo
que usted sabe
en este momento,
calcule el monto
en dólares de lo
perdido.

OPCIONAL

¿Ha tratado
de resolver
el problema
tomando alguna
de las siguientes
medidas?
OPCIONAL

COMUNICARSE
DIRECTAMENTE CON LA
EMPRESA

COMUNICARSE CON OTRA
AGENCIA
DEL GOBIERNO

INICIAR ACCIONES LEGALES

COMUNICARSE CON LA
OFICINA PARA LA PROTECCIÓN
FINANCIERA DEL CONSUMIDOR

CONTRATAR UN ABOGADO

OTRO

Incluya detalles como, por ejemplo, los nombres e información de contacto de los organismos
gubernamentales con los que se comunicó, las fechas en que se comunicó con ellos, los números
de caso, el estado de tramitación de los casos, la información de contacto del abogado (si
corresponde), etc.

NÚMERO DE QUEJA

¿NECESITA AY UDA CON ES TE FORMUL ARIO?
(855) 411- CFPB (2372)

FORMULARIO DE QUEJA SOBRE PRODUCTOS O SERVICIOS FINANCIEROS

Preguntas sobre préstamos hipotecarios (si corresponde)
La presentación de una queja no demorará ni detendrá, de forma automática, la ejecución hipotecaria.
Si la queja que usted presenta no tiene que ver con un préstamo hipotecario, omita esta página.
8

¿Le preocupa
la posibilidad
de perder su
propiedad debido
a la ejecución
hipotecaria?

SÍ
NO

OPCIONAL

¿Se ha atrasado
con los pagos
de su préstamo
hipotecario o está
en incumplimiento
de pago del mismo?

También debe marcar “Sí ” si la compañía hipotecaria
considera que usted está en incumplimiento de pago
o que se ha atrasado con los pagos, incluso si usted
cree que la compañía está equivocada.

SÍ
NO

OPCIONAL

¿Se ha fijado una
fecha para la venta
de su vivienda
por ejecución
hipotecaria?

Si ya se ha fijado la fecha para la venta de su vivienda por
ejecución hipotecaria, puede que usted haya recibido una
“Notificación de remate” u “Orden judicial de remate”.

SÍ
NO
NO SÉ

OPCIONAL

10a

De ser asi, ¿cuál
es la fecha
programada para
la venta de su
vivienda?

AAAA

Proporcione la fecha exacta, si puede. La
fecha debe aparecer en la “Notificación
de remate” u “Orden judicial de remate”.

OPCIONAL

¿Le pagó dinero a
una empresa para
que le ayudara a
evitar la ejecución
hipotecaria?

SÍ
NO

A este servicio se le denomina a veces “rescate (o
defensa o prevención) de la ejecución hipotecaria” o
“mitigación (o control) de pérdidas”.

OPCIONAL

NÚMERO DE QUEJA

¿NECESITA AY UDA CON ES TE FORMUL ARIO?
(855) 411- CFPB (2372)

3 DE 7

4 DE 7

FORMULARIO DE QUEJA SOBRE PRODUCTOS O SERVICIOS FINANCIEROS

Datos personales
12

Presento la queja
en representación:

MÍA

CONTESTE LA PREGUNTA 13, 13A Y 14

DE OTRA PERSONA

Datos del titular
de la cuenta

NOMBRE

CONTESTE LAS PREGUNTAS 13, 13A, 14 Y 15

APELLIDO(S)

SUFIJO

CALLE Y NÚMERO

CIUDAD

ESTADO

CORREO ELECTRÓNICO

13a

Edad del titular
de la cuenta

CÓDIGO POSTAL

PAÍS

TELÉFONO

EDAD

OPCIONAL

Número de cuenta

Información de
contacto de quien
presenta la queja

NOMBRE

Si usted presenta la
queja en representación de otra persona,
incluya aquí su propia
información para que
podamos informarle
sobre el estado de tramitación de la queja.

CALLE Y NÚMERO

APELLIDO(S)

CIUDAD

ESTADO

CORREO ELECTRÓNICO

SUFIJO

CÓDIGO POSTAL

TELÉFONO

NÚMERO DE QUEJA

¿NECESITA AY UDA CON ES TE FORMUL ARIO?
(855) 411- CFPB (2372)

PAÍS

5 DE 7

FORMULARIO DE QUEJA SOBRE PRODUCTOS O SERVICIOS FINANCIEROS

Datos de la empresa
16

Nombre de la
empresa

16a

Dirección de la
empresa

CALLE Y NÚMERO

OPCIONAL
CIUDAD

16b

ESTADO

CÓDIGO POSTAL

PAÍS

Teléfono
OPCIONAL

16c

Sitio web
OPCIONAL

Adjuntar
documentos
probatorios
OPCIONAL

Adjunte copias de cualquier documento que acredite la queja. La mejor manera en que
podamos entender su queja es si tenemos la versión completa de documentos como, por
ejemplo, contratos, cartas, estados de cuenta mensuales y comprobantes de transacciones.
No incluya el original de los documentos.

NÚMERO DE QUEJA

¿NECESITA AY UDA CON ES TE FORMUL ARIO?
(855) 411- CFPB (2372)

6 DE 7

FORMULARIO DE QUEJA SOBRE PRODUCTOS O SERVICIOS FINANCIEROS

Historial militar (si corresponde)
Hay algunas protecciones a las que se pueden acoger los militares y sus cónyuges y dependientes.
Si usted no tiene ninguna afiliación militar ni es cónyuge o dependiente de un militar, omita esta página.
17

El titular de la
cuenta es o era:

INTEGRANTE DE LAS FUERZAS ARMADAS (FF. AA.)

OPCIONAL

CÓNYUGE / DEPENDIENTE DE UN INTEGRANTE DE LAS FF. AA.

CONTESTE LA PREGUNTA 17A
CONTESTE LAS PREGUNTAS 17A Y 17B

(INDIQUE TODOS LOS
QUE CORRESPONDAN)

17a

Historial de
servicio militar
OPCIONAL
(ESCOJA UNA OPCIÓN
EN CADA COLUMNA)

17b

Datos personales
del integrante
de las fuerzas
armadas
OPCIONAL

Estado actual

Rama

Rango

EN ACTIVIDAD

EJÉRCITO

E1 - E4

DE RESERVA

MARINA

E5 - E7

GUARDIA NACIONAL

INFANTERÍA DE MARINA

E8 - E9

EN RETIRO

FUERZA AÉREA

O1 - O3

VETERANO
(EX COMBATIENTE)

SERVICIO DE GUARDACOSTAS

O4 - O6

SERVICIO DE SALUD PÚBLICA

O7 - O10

ADMINISTRACIÓN NACIONAL
DE OCÉANOS Y ATMÓSFERA

W01 - CW5

NOMBRE

APELLIDO(S)

SUFIJO

CALLE Y NÚMERO

CIUDAD

ESTADO

CÓDIGO POSTAL

NÚMERO DE QUEJA

¿NECESITA AY UDA CON ES TE FORMUL ARIO?
(855) 411- CFPB (2372)

PAÍS

FORMULARIO DE QUEJA SOBRE PRODUCTOS O SERVICIOS FINANCIEROS

7 DE 7

Certificación
La información proporcionada es verdadera a mi leal saber y entender.
Entiendo que la CFPB no puede actuar como mi abogado, un tribunal o un asesor financiero.

Aviso sobre la Ley de Privacidad
La información que usted proporcione permitirá a la
Oficina para la Protección Financiera del Consumidor
(CFPB) atender su queja o consulta sobre las empresas
y los servicios que supervisamos. La información sobre
su queja o consulta (incluidos datos confidenciales) se
puede poner a disposición de cualquiera de las siguentes partes:

Por medio de una base de datos de quejas, también
podemos poner a disposición del público su queja o
consulta (salvo los datos confidenciales).

▪
▪

No es obligatorio presentar una queja o proporcionar
datos confidenciales (incluyendo su número de Seguro
Social). Además, puede retirar su queja en cualquier momento. Sin embargo, si usted no incluye la información
solicitada, es posible que la CFPB no pueda tomar acción
en relación a su queja.

▪
▪
▪

la empresa que es objeto de su queja;
terceras partes, según sea necesario con el fin de obtener la información necesaria para atender la queja;
tribunales, partes litigantes, abogados, entidades
jurídicas o cortes administrativas, en el curso de un
proceso judicial o administrativo, o el Departamento
de Justicia;
otros organismos o autoridades reguladoras, ya sean
federales o estatales, para los fines establecidos por
la ley o para los fines de cumplimiento de la ley, o
contratantes, agentes y otras partes autorizadas por
la CFPB para recibir esta información.

El presente instrumento de recolección de datos está
autorizado por la Sección 5493 del Título 12 del Código
de los Estados Unidos (12 U.S.C. §5493).

Aviso sobre la recolección de información del consumidor
Número de control emitido por la Oficina de
Administración y Presupuesto (OMB): 3170-0011

3170-0011 y tiene vigencia hasta el 31 de mayo de 2015.
¿Tiene usted algún comentario o sugerencia? Envíenos
un mensaje a [email protected].

Utilizamos el presente formulario para recibir las quejas.
Si usted no desea presentar una queja, no está obligado
a llenar este formulario. Calculamos que se necesitan
entre 7 y 10 minutos para llenar el formulario. El número
de control emitido por la OMB para el formulario es

NÚMERO DE QUEJA

¿NECESITA AY UDA CON ES TE FORMUL ARIO?
(855) 411- CFPB (2372)

1 OF 8

SUBMIT A COMPLAINT ABOUT A FINANCIAL PRODUCT OR SERVICE

Debt Collection
What is this complaint about?
1

What type of debt
is this?
CHOOSE ONE

Which of these
best describes your
issue?

CREDIT CARD

MEDICAL

MORTGAGE

FEDERAL STUDENT LOAN

AUTO

NON-FEDERAL STUDENT LOAN

OTHER (I.E., PHONE, HEALTH
CLUB, ETC.)
I DON’T KNOW

OPTION NUMBER

ENTER THE NUMBER OF
THE OPTION THAT BEST

Communication tactics

DESCRIBES YOUR ISSUE
1A

Frequent or repeated
calls

Did not receive notice of
right to dispute

Not enough information
to verify debt (i.e. amount
of debt & name of
creditor)

Did not disclose
communication was an
attempt to collect a debt

Used obscene, profane or
other abusive language

Debt resulted from
identity theft

Debt was paid

Debt is not mine

Threatened to take legal
action

Called after sent written
cease of communication
notice

Improper contact or
sharing of information

Attempted to collect
wrong amount

Contacted me after I
asked not to

Impersonated attorney,
law enforcement or
government official

Contacted my employer
after I asked not to

If someone is
contacting you
by phone, what
number are they
calling?

Debt was discharged in
bankruptcy

Called outside of 8am9pm

Indicated committing
crime by not paying debt

Disclosure or
verification of debt

False statements or
representation

Continued attempts to
collect a debt I do not owe

Contacted me instead of
my attorney

Talked to a third party
about my debt

Indicated should not
respond to lawsuit

Taking or threatening to
take an illegal action
6A

Threatened to arrest me
or take me to jail if I do
not pay

Threatened to sue me on
debt that is too old to be
sued on

Sued me without properly
notifying me of lawsuit

Sued me where I did not
live or did not sign for the
debt

Collected or attempted
to collect exempt funds
(i.e. unemployment, child
support, etc.)

Seized or attempted to
seize property

PHONE NUMBER

OPTIONAL

CASE NUMBER

VERSION 3. 2 / 2015

2 OF 8

SUBMIT A DEBT COLLECTION COMPLAINT

What happened?
We want to know what happened. Providing facts and details like dates and where transactions occurred helps us
understand your complaint. For example, did someone call you? Did you visit a company in person?
4

Describe what
happened so we
can understand the
issue
Do not include
sensitive information
like your name, contact
information, account
number, or Social
Security Number in this
field. We will collect
certain personal
information at a later
step.

Desired Resolution
We want to understand what you think would be a fair resolution to this issue. We’ll forward this information to the
company along with your description of what happened so that all parties know what you are looking for.
5

What do you think
would be a fair
resolution to your
issue?
Do not include
sensitive information
like your name, contact
information, account
number, or Social
Security Number in this
field.

CASE NUMBER

VERSION 3. 2 / 2015

3 OF 8

SUBMIT A DEBT COLLECTION COMPLAINT

Who’s contacting you about this debt?
We want to know as much as you can tell us about the company collecting the debt. Even if you don’t know the company’s name, provide any phone numbers for the company, a representative name, or an account number and we’ll
try to match things up on our end.
6

Debt collection
company name

Company contact
information

I DON’T KNOW THE
DEBT COLLECTION
COMPANY NAME

STREET

OPTIONAL

Even if you don’t
know the company’s
name, please try
your best to provide
any phone numbers
for the company, a
representative name,
or an account number
and we’ll try to match
things up on our end.

CITY

Attach any
supporting
documents

Here we’re asking for copies of any documents about your complaint. Documents like
contracts, letters, monthly statements, and transaction receipts can help us better understand
your complaint.

STATE

REPRESENTATIVE NAME OR ID

ZIP CODE

COUNTRY

PHONE NUMBER

ACCOUNT NUMBER

CASE NUMBER

VERSION 3. 2 / 2015

4 OF 8

SUBMIT A DEBT COLLECTION COMPLAINT

Do you know where this debt came from?
We want to know if the company contacting you was hired by a different company to collect on a debt. If the debt is
with a different company, we’ll give you the option to submit two complaints about your issue: one complaint about
the debt collector and a second complaint about the company that owns the debt.
If you don’t know where the debt came from, choose “I don’t know.”
7

Do you know
where this debt
came from?

CONTINUE TO QUESTION 10

SAME COMPANY

FILL OUT QUESTIONS 8 & 9

DIFFERENT COMPANY

OPTIONAL,
CHOOSE ONE

Company name

Company contact
information
Even if you don’t
know the company’s
name, please try
your best to provide
any phone numbers
for the company, a
representative name,
or an account number
and we’ll try to match
things up on our end.

CONTINUE TO QUESTION 10

I DON’T KNOW

I DON’T KNOW THE
COMPANY NAME

STREET

CITY

STATE

REPRESENTATIVE NAME OR ID

ZIP CODE

PHONE NUMBER

ACCOUNT NUMBER

Submit a separate
complaint against
this company?

YES
NO

By selecting yes, we will create a separate complaint against this
company. This will be in addition to your complaint against the debt
collection company.

CASE NUMBER

VERSION 3. 2 / 2015

COUNTRY

5 OF 8

SUBMIT A DEBT COLLECTION COMPLAINT

Personal information
The company needs your full name and the last four digits of your Social Security Number to match your complaint to
their records and respond to your complaint.
10

Are you filing on
behalf of someone
else?

FILL OUT QUESTIONS 11 & 12

YES, I AM FILING ON BEHALF OF SOMEONE ELSE

FILL OUT QUESTION 11

NO, I AM FILING ON BEHALF OF MYSELF

Consumer’s
identification
information

FIRST NAME

We’ll use this
information to contact
you about the status of
your complaint.

STREET

LAST NAME

CITY

STATE

11a

Additional
identification

Contact
information of
person submitting
complaint

ZIP CODE

COUNTRY

PHONE NUMBER

LAST FOUR DIGITS OF SOCIAL SECURITY NUMBER

AGE

Companies match this information to their records to respond to your
complaint. Not providing may delay or prevent the company from
responding to your complaint.

OPTIONAL

SUFFIX

FIRST NAME

LAST NAME

SUFFIX

STREET

CITY

STATE

PHONE NUMBER

CASE NUMBER

VERSION 3. 2 / 2015

ZIP CODE

COUNTRY

6 OF 8

SUBMIT A DEBT COLLECTION COMPLAINT

Military affiliation
There are certain protections that apply to servicemembers and their spouses and dependents.
13

The consumer is
now or was:

A SERVICEMEMBER

OPTIONAL,

THE SPOUSE / DEPENDENT OF A SERVICEMEMBER

FILL OUT QUESTION 13A
FILL OUT QUESTIONS 13A & 13B

CHECK ALL THAT APPLY

13a

Service details

Current status

Branch

Rank

CHOOSE ONE
IN EACH COLUMN

13b

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

STREET

CITY

STATE

CASE NUMBER

VERSION 3. 2 / 2015

ZIP CODE

COUNTRY

7 OF 8

SUBMIT A DEBT COLLECTION COMPLAINT

Authorization
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.
SIGNATURE

DATE

Ways to submit this form
By mail
Consumer Financial Protection Bureau
PO Box 4503, Iowa City, IA 52244

By fax
(855) 237-2392

Other ways to submit your complaint
Online
consumerfinance.gov/complaint

CASE NUMBER

VERSION 3. 2 / 2015

Over the phone
(855) 411-2372

8 OF 8

SUBMIT A DEBT COLLECTION COMPLAINT

▪
▪
▪
▪
▪

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
OMB Control Number 3170-0011
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].

CASE NUMBER

VERSION 3. 2 / 2015

1 DE 8

FORMULARIO DE QUEJA SOBRE PRODUCTOS O SERVICIOS FINANCIEROS

Cobro de deudas
¿De qué se trata esta queja?
1

¿Qué tipo de
deuda es?
ESCOJA UNO

TARJETA DE CRÉDITO

CUENTAS MÉDICAS

PRÉSTAMO HIPOTECARIO

PRÉSTAMO ESTUDIANTIL FEDERAL

AUTOMÓVIL

PRÉSTAMO ESTUDIANTIL PRIVADO

¿Cuál de las
siguientes
opciones mejor
describe su
problema?

NÚMERO DE OPCIÓN

ESCRIBA EL NÚMERO DE

Llaman frecuentemente
o repetidamente

Llaman antes de las 8am
o después de las 9pm

La deuda fue eliminada
por quiebra

Usan lenguaje soez,
ofensivo o insultante

La deuda es el resultado
del robo de identidad

Amenazan con acción
legal

La deuda fue saldada

La deuda no es mía

Siguen llamando tras
recibir por escrito
que suspendan
comunicaciones

Tácticas de comunicación

LA OPCIÓN QUE MEJOR
DESCRIBA SU PROBLEMA

Falsa declaración o
representación
4A

Si alguien se está
comunicando con
usted por teléfono,
¿a qué número
está llamando?

Intentaron cobrar un
monto indebido
Se hicieron pasar
por abogados o por
funcionarios del orden
público o del Gobierno

Intentos repetidos de
cobrar deudas que no me
corresponden

Comunicación
inoportuna o cesión
indebida de datos
5A

No hicieron caso a mi
petición de que no se
comunicaran conmigo

No hicieron caso a mi
petición de que no se
comunicaran con mi
empleador

Se comunicaron conmigo
y no con mi abogado

Hablaron con terceros
sobre mi deuda

Indicaron que violé la ley
al no pagar la deuda
Indicaron que no debo
responder a la demanda

OTRO (TELÉFONO,
GIMNASIO, ETC.)
NO SÉ

Omisión de información
obligatoria o de la
verificación de la deuda
3A

No me informaron sobre
mi derecho a impugnar la
validez de la deuda

No hay información
suficiente para verificar
la validez de la deuda (el
monto y el acreedor)

No me informaron que
era un intento de cobrar
una deuda

Amenazas o iniciación de
medidas ilegales
6A

Amenazaron con arrestarme
o llevarme a la cárcel si no
pago la deuda

Amenazaron con
demandarme por una
deuda que está exenta
por su antigüedad

Me demandaron sin darme
la debida notificación

Me demandaron en un lugar
donde no residí o donde no
contraje la deuda

Embargaron o intentaron
embargar ingresos que
están exentos para efectos
del cobro de la deuda
(seguro de desempleo,
pensión para los hijos, etc.)

Tomaron posesión de
bienes o intentaron hacerlo

TELÉFONO

OPCIONAL

NÚMERO DE CASO

VERSIÓN 3.0 / 2013

FORMULARIO DE QUEJA SOBRE EL COBRO DE DEUDAS

2 DE 8

¿Qué pasó?
Queremos saber lo que sucedió. Si usted nos proporciona los detalles de lo ocurrido —como las fechas y lugares de
las transacciones—entonces podremos entender mejor su queja. Por ejemplo: ¿Alguien le llamó por teléfono? ¿Usted
visitó la empresa en persona?
4

Describa lo que
pasó, para que
podamos entender
el problema.
No incluya aquí sus
datos confidenciales,
como su nombre y
apellido, información
de contacto, número
de cuenta o número
de Seguro Social. Le
pediremos algunos de
estos datos en un paso
posterior.

¿Qué piensa usted
que sería una
resolución justa del
problema?
No incluya aquí sus
datos confidenciales,
como su nombre y
apellido, información
de contacto, número
de cuenta o número de
Seguro Social.

NÚMERO DE CASO

VERSIÓN 3.0 / 2013

3 DE 8

FORMULARIO DE QUEJA SOBRE EL COBRO DE DEUDAS

¿Quién se ha comunicado con usted respecto a esta deuda?
Queremos saber tanto como usted nos pueda decir sobre la empresa que intenta cobrar la deuda. Aunque no sepa
el nombre de la empresa, trate de proporcionar algún número de teléfono para la misma, el nombre de alguno de
sus representantes o un número de cuenta. Por nuestra parte, haremos todo lo posible para localizar la empresa.
6

Nombre de la
empresa de cobro
de deudas

Información de
contacto de la
empresa de cobro
de deudas
OPCIONAL

Aunque no sepa el
nombre de la empresa,
trate de proporcionar
algún número de
teléfono para la misma,
el nombre de alguno
de sus representantes
o un número de
cuenta. Por nuestra
parte, haremos todo lo
posible para localizar
la empresa.

Adjuntar
documentos
probatorios
OPCIONAL

NO SÉ EL NOMBRE
DE LA EMPRESA

CALLE Y NÚMERO

CIUDAD

ESTADO

NOMBRE O IDENTIFICACIÓN DEL REPRESENTANTE

CÓDIGO POSTAL

PAÍS

TELÉFONO

NÚMERO DE CUENTA

NÚMERO DE CASO

VERSIÓN 3.0 / 2013

4 DE 8

FORMULARIO DE QUEJA SOBRE EL COBRO DE DEUDAS

¿Quien es el acreedor de esta deuda?
Queremos saber si la empresa que se puso en contacto con usted fue contratada por otra empresa para cobrar la
deuda. Si esta otra empresa es el acreedor de la deuda, le daremos a usted la oportunidad de presentar dos quejas:
una contra la empresa de cobro de deudas y otra contra la empresa acreedora.
Si usted no sabe quien es el acreedor de la deuda, elija “No sé”.
7

¿Sabe quien es el
acreedor de esta
deuda?

LA MISMA EMPRESA QUE COBRA LA DEUDA

OPCIONAL

NO SÉ

PASE A LA PREGUNTA 10

Nombre de la
empresa acreedora

Información de
contacto de la
empresa acreedora

CALLE Y NÚMERO

CIUDAD

¿Desea presentar
por separado
una queja contra
la empresa
acreedora?

CONTESTE LAS PREGUNTAS 8 Y 9

OTRA EMPRESA ACREEDORA

PASE A LA PREGUNTA 10

NO SÉ EL NOMBRE
DE LA EMPRESA

ESTADO

NOMBRE O IDENTIFICACIÓN DEL REPRESENTANTE

CÓDIGO POSTAL

PAÍS

TELÉFONO

NÚMERO DE CUENTA

SÍ
NO

Si usted elije “Sí ”, iniciaremos por separado la gestión de una queja
contra la empresa acreedora. Como resultado, se dará trámite a dos
quejas en total: una contra la empresa de cobro de deudas y otra
contra la empresa acreedora.

NÚMERO DE CASO

VERSIÓN 3.0 / 2013

5 DE 8

FORMULARIO DE QUEJA SOBRE EL COBRO DE DEUDAS

Datos personales
Usted debe proporcionar su nombre completo y los cuatro últimos dígitos de su número de Seguro Social para que la
empresa pueda encontrar su expediente y responder a su queja.
10

Datos de
información
de contacto

NOMBRE

APELLIDO(S)

Vamos a usar estos
datos para informarle
sobre el estado de
tramitación de su
queja.

CALLE Y NÚMERO

CIUDAD

ESTADO

CORREO ELECTRÓNICO

10a

Otros datos de
identificación

Otro contacto

CÓDIGO POSTAL

PAÍS

TELÉFONO

CUATRO ÚLTIMOS DÍGITOS DE SU NÚMERO DE SEGURO SOCIAL

EDAD

Las empresas utilizan esta información para encontrar en sus registros
el expediente del cliente y responder a las quejas. La omisión de estos
datos puede demorar o imposibilitar la respuesta de la empresa.

OPCIONAL

SUFIJO

NOMBRE

APELLIDO(S)

SUFIJO

OPCIONAL

Utilice esta sección
si desea que le
informemos a otra
persona sobre el
estado de tramitación
de la queja.

CALLE Y NÚMERO

CIUDAD

ESTADO

TELÉFONO

NÚMERO DE CASO

VERSIÓN 3.0 / 2013

CÓDIGO POSTAL

PAÍS

6 DE 8

FORMULARIO DE QUEJA SOBRE EL COBRO DE DEUDAS

Historial militar
Hay algunas protecciones a las que se pueden acoger los militares y sus cónyuges y dependientes.
12

El consumidor es
o era:
OPCIONAL
(INDIQUE TODOS LOS

CONTESTE LA PREGUNTA 12A

INTEGRANTE DE LAS FUERZAS ARMADAS (FF. AA.)

CONTESTE LAS PREGUNTAS 12A Y 12B

CÓNYUGE / DEPENDIENTE DE UN INTEGRANTE DE LAS FF. AA.

QUE CORRESPONDAN)

12a

Historial de
servicio militar
ESCOJA UNA OPCIÓN
EN CADA COLUMNA

12b

Datos personales
del integrante
de las fuerzas
armadas

Estado actual

Rama

Rango

ACTIVO

EJÉRCITO

E1 - E4

RESERVA

MARINA

E5 - E7

GUARDIA NACIONAL

INFANTERÍA DE MARINA

E8 - E9

EN RETIRO

FUERZA AÉREA

O1 - O3

VETERANO
(EX COMBATIENTE)

SERVICIO DE GUARDACOSTAS

O4 - O6

SERVICIO DE SALUD PÚBLICA

O7 - O10

ADMINISTRACIÓN NACIONAL
DE OCÉANOS Y ATMÓSFERA

W01 - CW5

NOMBRE

APELLIDO(S)

SUFIJO

CALLE Y NÚMERO

CIUDAD

ESTADO

NÚMERO DE CASO

VERSIÓN 3.0 / 2013

CÓDIGO POSTAL

PAÍS

7 DE 8

FORMULARIO DE QUEJA SOBRE EL COBRO DE DEUDAS

Certificación
La información proporcionada es verdadera a mi leal saber y entender.
Entiendo que la CFPB no puede actuar como mi abogado, un tribunal o un asesor financiero.
FIRMA

FECHA

Maneras de presentar este formulario
Por correo
Oficina para la Protección Financiera Del Consumidor
PO Box 4503, Iowa City, IA 52244

Por fax
(855) 237-2392

Otras maneras de presentar su queja
Por Internet
consumerfinance.gov/complaint

NÚMERO DE CASO

VERSIÓN 3.0 / 2013

Por teléfono
(855) 411-2372

8 DE 8

FORMULARIO DE QUEJA SOBRE EL COBRO DE DEUDAS

▪
▪
▪
▪
▪

la empresa que es objeto de su queja;
terceras partes, según sea necesario con el fin de
obtener la información necesaria para atender la
queja;
tribunales, partes litigantes, abogados, entidades
jurídicas o cortes administrativas, en el curso de un
proceso judicial o administrativo, o el Departamento
de Justicia;
otros organismos o autoridades reguladoras, ya sean
federales o estatales, para los fines establecidos por
la ley o para los fines de cumplimiento de la ley, o
contratantes, agentes y otras partes autorizadas por
la CFPB para recibir esta información.

Por medio de una base de datos de quejas, también
podemos poner a disposición del público su queja o
consulta (salvo los datos confidenciales).
El presente instrumento de recolección de datos está
autorizado por la Sección 5493 del Título 12 del Código
de los Estados Unidos (12 U.S.C. §5493).
No es obligatorio presentar una queja o proporcionar
datos confidenciales (incluyendo su número de Seguro
Social). Además, puede retirar su queja en cualquier
momento. Sin embargo, si usted no incluye la información solicitada, es posible que la CFPB no pueda tomar
acción en relación a su queja.

Aviso sobre la recolección de información del consumidor
Número de control emitido por la Oficina de
Administración y Presupuesto (OMB): 3170-0011
Utilizamos el presente formulario para recibir las quejas.
Si usted no desea presentar una queja, no está obligado
a llenar este formulario. Calculamos que se necesitan
entre 7 y 10 minutos para llenar el formulario. El número
de control emitido por la OMB para el formulario es
3170-0011 y tiene vigencia hasta el 30 de noviembre
del 2014. ¿Tiene usted algún comentario o sugerencia?
Envíenos un mensaje a [email protected].

NÚMERO DE CASO

VERSIÓN 3.0 / 2013

CONSUMER RESPONSE CENTER
AGENT CALL SCRIPTS
Version 5.01

(Presented in script # order)

March 1, 2015

Agent Scripts

March 1, 2015 V5.01

Script #

Script Text

Comments/Notes

Good ! Thank you for calling the Consumer Financial Protection Bureau.

Note: Script page number NOT
visible.

Does record auto-populate from IVR?
button
If the caller speaks Spanish transfer to 330002.

Agent Scripts

March 1, 2015 V5.01

Script #

Comments/Notes

Script Text
button

{If case does not auto populate AND caller says case is on file}

Verify the caller: I need to ask a couple of questions to verify your identity.
- Can you provide the case number?
- What is your name? Conduct Search and then confirm contact or complainant’s name.
- Can you verify the address, including Zip code and email address?
- If no address: What is the email address provided for the case?
button
button
02

To get started is there a phone number where I can reach you if we get disconnected?

What product or service can I help you with today?

HT: Don’t forget to CONFIRM THE PURPOSE OF THE CALL as soon as callers tell you their issue or
reason for the call.
High Level Product*

{Dynamic, if High Level Product = Payday loan}

Does this concern debt collection of a payday loan?*

{if YES is selected, the following helper text will display}

NOTE: if “Yes” is selected, the product will be changed to “Debt collection” with sub-product “Payday
loan”

Default Value
“Does this concern … payday
loan?*” = NO
Default Value
“Does this concern..debt
collector?*” = NO

{Dynamic, if Product /sub-product = Other financial service/debt settlement}
Does this concern a problem with a debt collector?*

{Dynamic, if Product /sub-product = Other financial service/credit repair}
Does this concern a problem with your credit report or score?*

Default Value
“Does this concern..credit
report?*” = NO

Agent Scripts

March 1, 2015 V5.01

Script #

Comments/Notes

Script Text
< PRODUCT SELECTION HINTS (Click here) > button

{Dynamic, if agent clicks to open Product selection hints}
1) Bank account or service for checking and savings accounts, debit cards, CDs, cashing a check without
an account or other bank services.
2) Credit card
3) Consumer loan for vehicle loans and leases, installment loans (e.g. medical, appliance, vacation,
funeral), title loans, pawn loans or a personal line of credit.
4) Credit reporting for incorrect information on a credit report, problems with a credit reporting company's
investigation, improper use of a credit report, inability to obtain a credit report, credit monitoring or identity
protection services.
5) Debt collection for problems related to attempts to contact you by a collection company regarding debt
owed, or alleged to be owed.
6) Money transfers for transfers of money within the U.S. and internationally.
7) Mortgage for mortgages, second mortgages, home equity lines of credit, reverse mortgage, etc.
8) Non-product inquiry for any question that is not about one of the products listed above.
9) Other financial service for non-bank check cashing services, credit repair (EXCEPT for problems with a
credit report}, debt settlement (EXCEPT for a problem with a debt collector), foreign currency exchange,
money orders, refund anticipation checks and traveler’s or cashier’s checks.
10) Payday loan for all problems related to payday loans, EXCEPT those concerning lender collection
practices on a payday loan, which should be identified as a “Debt collection” complaint
11) Prepaid card for general reloadable prepaid cards, government benefit payment cards (e.g
unemployment, social security), EBT cards (e.g. WIC,TANF,SNAP), ID prepaid cards (e.g. students),
transit cards, gift or merchant cards, mobile wallets, payroll cards, and other special purpose cards.
12) Student loan for Federal (Stafford, Direct, Consolidation, PLUS, Perkins), Non-federal (e.g. private,
alternative, or other student loan).
HT: If the caller is asking about a product not mentioned above, go to and follow Answer 1836.
Afterwards, click “Go to closing” and select the product/sub-product that best fits the topic.

If the caller is speaking Spanish or has been transferred to a Spanish speaking agent:
Could you confirm that you would like to receive written communication from us in Spanish?* (If Yes,

Default value:
Language Preference: ENGLISH

Agent Scripts

March 1, 2015 V5.01

Script #

Comments/Notes

Script Text
Select Spanish.)

button

button
button
button
04

Deleted

{If caller has a Question}

[standard
script page]

If the consumer has not already provided their question, say:
I would be more than happy to research your inquiry to try and provide you an answer.
What specific question did you have?
Search the Knowledgebase using keywords.
If the answer is not readily available in the Knowledgebase, check the Consumer Action Handbook. If
product falls outside CFPB scope, refer to Knowledgebase 1836.
OR
Go to consumerfinance.gov/askcfpb and search for an answer.
If information is in CFPB scope and still not found:
Unfortunately, I can't find any information about your specific question. To request that your question be

Agent Scripts

March 1, 2015 V5.01

Script #

Comments/Notes

Script Text
added to our database of FAQs about financial issues, visit on our website at
consumerfinance.gov/askcfpb. Ask CFPB is an interactive online tool for helping consumers find clear
unbiased answers to financial questions. If you select the option to have us contact you by email, we’ll let
you know if your question is answered and added to Ask CFPB. You also always have the option to
continue with a complaint if desired. HT: CFPB Phone # : 1 (855) 411-CFPB (2372)
Would you like to continue with either of these?
If consumers choose to submit their questions, offer to guide them to the Add a New Question
button on our website.
(Agents may also offer to submit it online or through our Propose button for consumers if
requested.
If consumers wish to submit complaints, click “Click if consumer wants to file complaint” button.
If consumers say no, click “Go to closing” button.
button
button
button
button

6
[2015
customer
service
survey
page –
temporary
language
highlighted]

{If caller has a Question}

If the consumer has not already provided their question, say:
I would be more than happy to research your inquiry to try and provide you an answer. Also, at the end
you’ll have a chance to take a short survey to help us improve this service. Now, what specific question
did you have?
Search the Knowledgebase using keywords.
If the answer is not readily available in the Knowledgebase, check the Consumer Action Handbook. If
product falls outside CFPB scope, refer to Knowledgebase 1836.
OR
Go to consumerfinance.gov/askcfpb and search for an answer.
If information is in CFPB scope and still not found:
Unfortunately, I can't find any information about your specific question. To request that your question be
added to our database of FAQs about financial issues, visit on our website at
consumerfinance.gov/askcfpb. Ask CFPB is an interactive online tool for helping consumers find clear
unbiased answers to financial questions. If you select the option to have us contact you by email, we’ll let
you know if your question is answered and added to Ask CFPB. You also always have the option to

Agent Scripts

March 1, 2015 V5.01

Script #

Comments/Notes

Script Text
continue with a complaint if desired. HT: CFPB Phone # : 1 (855) 411-CFPB (2372)
Would you like to continue with either of these?
If consumers choose to submit their questions, offer to guide them to the Add a New Question
button on our website.
(Agents may also offer to submit it online or through our Propose button for consumers if
requested.
If consumers wish to submit complaints, click “Click if consumer wants to file complaint” button.
If consumers say no, click “Go to closing” button.
button
button
button
button

{If HL product is Credit Card}

To best assist you, I need to ask you a few questions.
Does your card say “debit” or “check card” on the front of it?
< Select YES or NO>

{If product says Debit/Check card}

Since your card says [debit/check] card, is it associated with your checking account or your savings
account?
Select Product*.

{If YES, then fill in this question}

Original Dispute Case Number
24

Are you calling *
__ about your personal mortgage or on behalf of a family member or friend?
__ on behalf of a mortgage related company?
button
button
button

{If the person is calling “on behalf of a mortgage related company” (from S#24)}
We are not able to address industry questions over the phone, but I would be happy to provide you with
an email address where you can submit your question or concern.

Agent Scripts

March 1, 2015 V5.01

Script #

Comments/Notes

Script Text
The email address is [email protected] (Note: ONLY for industry use).
button
button
button

If consumer has already identified one of the issues below, confirm and select their issue below.

4/13/13 Note: Remove

If consumer has NOT identified the reason for calling then say: "I'd be happy to help you with that. Are
you unable to make payment and concerned about foreclosure, OR do you have a mortgage complaint
about a specific institution OR do you have general questions about the mortgage process?" Based on
consumer's response, select option below.
__ 1) Has a concern about foreclosure or is unable to make payments
__ 2) Has a question about their loan or the mortgage process
__ 3) Has a mortgage related complaint regarding a specific institution
button
button
button
27

Is this about something you observed while working for a financial institution or financial service
provider?*

{Dynamic, if No to Send to Company}

For most complaints, the CFPB forwards some information to the company you identify. If you do not
want us to send any information to them, we may not be able to take action. All complaints will be used to
help the CFPB understand consumers’ experiences and monitor providers of financial products and
services.
button
button
button
28

Before we begin, let me describe the complaint process to you so you will understand what to expect.

We've tried to make it as easy as possible to submit a complaint. The best way to submit is on our
website consumerfinance.gov. This is the most time-effective for you, as well as the most accurate for us.
You can also submit a complaint by phone, mail, or fax. However, if you plan on attaching any supporting
documentation, you may want to submit online or by fax or mail.
Once you have submitted your complaint, it will be sent to the company for review and they will have 15
calendar days to respond to your complaint. If you provide an email address, you will receive electronic
notices about your complaint and will be able to access that information online at consumerfinance.gov.
Your email address will serve as your login ID and you will need to create a password the first time you
login.

{If Product / Sub Product = Money transfer/International…}

It’s a good idea to also contact the company as soon as possible if you think it made a mistake.

Agent Scripts

March 1, 2015 V5.01

Script #

Comments/Notes

Script Text
Information about how to contact the company may be on the receipt you received.
Which method do you prefer to submit your complaint?
__ Web
__ Phone
__ Fax/Mail/Paper Form
button
button

28
I will be happy to take your complaint over the phone. I do need to inform you that you will not be able to
attach any documentation to your complaint after I open a case for you today. If you have documentation
to add to your complaint, you may complete your complaint on our website and attach your documents, or
submit your complaint to CFPB by fax or by mail. Would you still like to submit your complaint by phone
today?
Before we begin, I need to read to you official disclosure statements to make sure that you understand
your rights and what we can provide as a part of this process. After I read the statements, I will ask you if
you understood.
The Paperwork Reduction Act is a federal law that requires the approval of certain federal questionnaires.
The Office of Management and Budget has approved these questions under the Paperwork Reduction
Act. On average, answering these questions takes about 10 minutes. The length of time to complete your
complaint depends on the complexity of the complaint.
Also, a federal law called the Privacy Act directs how the federal government (or the CFPB) collects,
keeps and shares your personal, private Information- including the personal information contained in your
answers to these questions. To understand how and when your information may be shared, you can read
the Privacy Act Statement on our website, consumerfinance.gov.
The Consumer Financial Protection Bureau cannot act as a court of law or as a lawyer on your behalf,
and we cannot give you legal or financial advice.
Do you understand these disclosures as I have read them to you?*

{If NO, go to closing as an Inquiry}

Additional References:
Privacy Act Statement Knowledgebase answer 230
Process the complaint will follow: Knowledgebase answer (not yet developed)
button
button
button
30

Do you want to submit this form to CFPB anonymously?*
buttons
button
button
button

{Skip this script for HL Product = Debt collection}

Product:
Credit card,
Consumer
loan (incl.
Title &
Pawn),
Bank
Acct/Svc.
Student
loan,
Mortgage,
Money
transfer

{For HL Products other than Credit Reporting & Payday; allows both ‘yourself ‘ AND ‘someone’ else to be
selected concurrently}
Are you filing on behalf of yourself?* < select YES or NO>
On behalf of someone else?

{If the Contact is the Sender or the Recipient, Contact name and address (not phone or email) should be
copied to the Sender or Recipient field accordingly, upon saving the case}
{Dynamic if filing on ‘behalf of someone else.}

Default Values:
• Are you filing…yourself?
= YES
• Are you filing..someone
else? = “Choose”
•

Are You = Choose

Agent Scripts

March 1, 2015 V5.01

Script #

Comments/Notes

Script Text
Relationship (to the someone else)*
{Dynamic if filing on ‘behalf of someone else = YES}
Relationship (to the someone else)*

{Dynamic section if Answer = YES}

Have you missed payments or are you in default on your mortgage? This includes if your mortgage
company believes you are in default or have missed payments, even if you believe your mortgage
company is in error.

{Dynamic if preceding answer is YES}

What is the date of the scheduled foreclosure sale?

button
button
button

{Credit card product only}

If you lost money, how much money did you lose?
When did this happen?
Have you done any of these things to try to resolve this issue?
Contacted the Consumer Financial Protection Bureau
Contacted Gov’t Agency
button
button
button

REMOVED (Discrimination scripting)

35
Describe your complaint. Include facts about what happened and any steps you have taken to resolve the
issue.

Dynamic, HL Product = Payday loan}
{If Issue = Charged unexpected fees or interest} Please include in your explanation the amount of fees or
interest that was paid.

{If Issue = Cannot stop charges to bank account} Please include in your explanation the name of the bank

REMOVED BASED ON CR367
(Aug. 2013)

Agent Scripts

March 1, 2015 V5.01

Script #

Comments/Notes

Script Text
and the state in which this bank is located.

{If Issue = Charged bank acct wrong day or amt.} Please indicate in your explanation whether this
resulted in an overdraft fee.
If consumer attempts to provide sensitive personal information in this description, note that we collect
account numbers and other sensitive information later in the process in order to have it in a separate
place and help protect their privacy.
Enter the company name provided by the consumer. If there is an exact match, you may select from the
list. Otherwise, enter the full name as provided by the consumer. If clarification is needed, ask or confirm
what company name shows up on their statement/receipt. If the consumer does not know the company,
enter Unknown.

{Dynamic, Hidden if HL Product = Debt collection }
Company (As stated by consumer)*
I am going to be typing everything you say verbatim. Would you mind speaking at a moderate pace?
Enter complaint description (What Happened).*

{Dynamic, applies to HL Product = Money transfer}

How much was transferred?
Amount MUST be in 0.00 format.
Is that amount in U.S. dollars or other currency?
{If NO}
Address1*
Address2 (fill in address, Optional>
City*
State*
Zip Code*
Country*
Account or Loan number (or Social Security number for Student Loans) Only ask for the Social Security
number if the Product is Student Loan.

{Credit card}

Ask for BILLING ADDRESS.

Is the Account/Billing/Property address same as the primary contact’s address?
{If NO}
Address1*
Address2 (fill in address, Optional>
City*
State*
Zip Code*
Country*
Account or Loan number (or Social Security number for Student Loans)
Only ask for the Social Security number if the Product is Student Loan.

{Consumer loan}

Ask for BILLING ADDRESS.

Is the Account/Billing/Property address same as the primary contact’s address?
{If NO}
Address1*
Address2 (fill in address, Optional>
City*
State*
Zip Code*
Country*
Account or Loan number (or Social Security number for Student Loans) Only ask for the Social Security
number if the Product is Student Loan.

Social Security number MUST be entered in the format ###-##-####.

{Credit reporting - INACTIVE}

Name on credit report
Social Security Number
Date of Birth
Name: Insert in First Middle Last order.
Social Security Number: Enter as xxx-xx-xxxx.
Date of Birth: Enter in mm/dd/yyyy format only.
Social Security number MUST be entered in the format ###-##-####.

{All products}

What company is this complaint about?
COMPANY ADDRESS

Company (As stated by consumer)*
Address 1
Address 2
City
State

Agent Scripts

March 1, 2015 V5.01

Script #

Comments/Notes

Script Text
Zip
Country

{Dynamic, HL product = Other financial service, Prepaid card}
Phone number
If the consumer is concerned about providing account information: We use unique information about your account to
verify that we have the right person to provide to the company and to help make sure the company reviews the
correct account information. The more information you provide, the easier it will be to review and process your
complaint.

button
button
button
38
Product:
Payday
loan
Consumer
loan/ Title
and Pawn
Loans

{Dynamic, HL Product = Payday loan, Consumer loan/Title Loan, Pawn Loan}
Where did you get the loan?

If the consumer asks why we need this information, say “This is important because different states have
different laws for payday loans.”

{Dynamic, if “Online” selected}

What is the website you used to apply for the payday loan?

What company is this complaint about?
COMPANY NAME & ADDRESS

Company (As stated by consumer)*
Address 1
Address 2
City

Default values:
• Company State =
Choose
• Company Country = US

Agent Scripts

March 1, 2015 V5.01

Script #

Comments/Notes

Script Text
State
Zip
Account or Loan number (or Social Security number for Student Loans) Only ask for the Social Security
number if the Product is Student Loan.

If the consumer is concerned about providing account information: We use unique information about your account to
verify that we have the right person to provide to the company and to help make sure the company reviews the
correct account information. The more information you provide, the easier it will be to review and process your
complaint.

button
button
button
39

Are you a Servicemember or Dependent?
Are you a dependent/spouse of a current/former servicemember?*
What is the servicemember’s branch of service?*

{Dynamic if Answer is YES to ‘dependent/spouse’ question above}
Salutation
First Name*
Middle Name
Last Name*
Suffix
Country*
Address 1*

Default Values:
• Are you a
Servicemember or
Dependent = “Choose”

Agent Scripts

March 1, 2015 V5.01

Script #

Comments/Notes

Script Text
Address 2
City*
State*
Zip code*
button
button
button

Before I submit your case, I would like to recap your complaint and your desired resolution.

What Happened?*
Desired Resolution?*
For CFPB tracking purposes, can you provide me with your age?

Thank you.
Is the information provided true to the best of your knowledge and belief and do you understand that the
Consumer Financial Protection Bureau cannot act as a court of law or a lawyer on your behalf, and we
cannot give you legal or financial advice?
Do you agree?*

{Dynamic, if YES}

Status*
Agent Reminder Notes:
1. Do not provide consumers with a case number unless the consumer specifically asks for a case
number.
2. Be sure to include information about a referral as a Private Note (on the Message tab).
3. Be sure to click the button FOLLOWED BY the button to properly save
the case.
Thank you for calling the CFPB. You can also find more information at consumerfinance.gov.
button

{After clicking, button, this ‘closing pop up is displayed.}
button

button
button
60

Before we close may I have your name?

[2015
customer

Contact*

Note: All fields will become
“READ ONLY” after the “Submit
Inquiry” button is clicked and the

Agent Scripts

March 1, 2015 V5.01

Script #

Script Text

Comments/Notes

service
survey
page –
temporary
script
language
highlighted]

button

closing pop up is displayed.

Product*
Which best describes your issue?*
Disposition*

{DYNAMIC, If answer to above question is “NO””
We are only able to take Debt collection complaints by phone if you are filing individually. I’d be happy to
have a debt collection complaint form sent to you by mail. You’ll need to make sure that both you and the
other party sign the form before returning it to us.
button
button
button
button
66

{If High Level Product = Debt collection}
{If sub Product = Payday loan}
Where did you get the payday loan?

If the consumer asks why we need this information, say: ”This is important because different states have
different laws for payday loans.”
{Dynamic, if “Online” selected}
What is the website you used to apply for the payday loan?

What company is contacting you about this debt?*
Enter the company name provided by the consumer. If there is an exact match, you may select from the
list. Otherwise, enter the full name as provided by the consumer.
If caller does not know name of debt collection company, click on the 'Unknown Company' button

If caller says company is the Department of Education or Federal Student Aid, click on the 'Department of Education'
button. button

{Dynamic, appears if the company is unknown}

Since you don’t know the name of the company we will be unable to send this complaint to a company.
All complaints will be used to help the CFPB understand consumers’ experiences and monitor providers
of financial products and services. If you are able to identify the company that is contacting you in the next
30 days, you can provide that information by calling us.

{Dynamic, appears if company is NOT “unknown”}

Do you have an address for this company?
Address 1
Address 2
City
State
ZIP code
Country
This is the caller’s phone number that the debt collector is dialing.
Can you provide a phone number the company is calling you from?

{Dynamic, appears if one phone number is provided}

Is there a second phone number that they’ve called you from?

This phone number is the number that appears in the caller ID on a phone or may have been provided by
the company.
Do you know the name or ID # of the debt collection company’s representative who you’ve spoken to?

Do you have an account number used by the debt collector when they contact you?

May I have the last 4 digits of your Social Security Number?

Do you know where this debt came from?
button
button
button
If caller is confused by the above question, say “We want to know if the people contacting you were hired
by another company to collect their debts. If your debt has come from a different company, we'll give you
the option to file two complaints about your issue: one complaint with the debt collector and a second
complaint with the company that owns the debt. If you don't know where the debt came from, you should
select the "I don't know" option.”
button
button
button
-routing67

{If High Level Product = Debt collection and “do you know where debt came from?” = Different Company
(in S#66)}

Agent Scripts

March 1, 2015 V5.01

Script #

Comments/Notes

Script Text
What is the name of the original creditor company?*
Enter the company name provided by the consumer. If there is an exact match, you may select from the
list. Otherwise, enter the full name as provided by the consumer.
If caller does not know name of debt collection company, click on the 'Unknown Company' button

If caller says company is the Department of Education or Federal Student Aid, click on the 'Department of Education'
button. button

{Dynamic, appears if the company is unknown}

Since you don’t know the name of the company we will use your complaint to help the CFPB understand
consumers’ experiences and monitor providers of financial products and services. If you are able to
identify the creditor in next 30 days, you can provide that information by calling us.
Do you want to submit a complaint against this company too?*