Consumer Response Intake Forms

Inventory of Questions for the Consumer Financial Protection Bureau’s
Consumer Response Intake Form (OMB No. 3170-0011)
INSTRUCTIONS
You should fill out this form if you have a complaint, comment, or question about a financial institution,
financial product, or financial service, or the Consumer Financial Protection Bureau (CFPB). The more
information you provide, the better we will be able to understand your issue.
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I.

Once we receive your form, we will provide you with a case number. Keep this case number for
future contact with the CFPB.
For most complaints, the CFPB forwards some information from this form to the company you
identify. You can submit information anonymously, but 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.
If you are filing a complaint on behalf of someone else, we may need this person’s signed,
written permission to take action. Except where noted, all questions refer to the consumer with
the issue.
Whistleblowers who currently or have previously worked at or with a financial institution should
contact us directly via phone or email. Learn more 1.
Review the Privacy Act Statement found here 2 and save or print it for your records.
We cannot act as a court of law or as a lawyer on your behalf and cannot give you legal or
financial advice.

ABOUT THE ISSUE
The “About the Issue” section is designed to capture information needed by the CFPB to investigate
and respond to complaints, whistleblower complaints, comments and questions about financial
institutions, financial products, or financial services, and comments or questions about the CFPB.
1. I have a: *
[CHECKBOX]
• Complaint about something that happened to me involving a financial institution, product,
or service;
• Alert about a financial institution, product, service, or practice that I think the CFPB should
look into;

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http://www.consumerfinance.gov/blog/the-cfpb-wants-you-to-blow-the-whistle-on-lawbreakers/
Privacy Act Statement quote:

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 party 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.

* Answers to these questions are necessary for CFPB take action

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Inventory of Questions for the Consumer Financial Protection Bureau’s
Consumer Response Intake Form (OMB No. 3170-0011)
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Comment or Question about a financial institution, product, service, or practice or the CFPB;

Prompts for item 2, Item 6, and Item 10 are driven by the user’s selection in the web form.
2. What happened?: *
[TEXT]
• Describe your complaint. Include facts about what happened and any steps you have taken
to resolve the issue. (Go to Item 3)
• Share your story. Tell us about what happened. (Go to Item 3)
• Tell us your question or comment. (Go to Item 5, Item 6, Item 15, and Items 17 onwards)
Item 2 of the web intake form will use “natural language processing” to suggest possible
products, sub-products, issues, sub-issues, and fair resolutions in Item 5, Item 6, and Item 9.
Consumers will also have the option in the web form to “tag” key words to help the Consumer
Financial Protection Bureau process their brief text description.
3. Is this about something that happened to you / someone you know? *

[CHECKBOX]

4. Is this about something you observed while working for a financial institution or financial service
provider? *
[CHECKBOX]
Employees of a bank or other consumer financial service provider may be entitled to certain protections.
For more information visit www.whistleblowers.gov.
Item 3 and Item 4 are designed to identify whistleblower complaints. If “No” to Item 3 and “Yes” to Item
4, go to Item 10.
5. This is about: *
Check only one.
a. Product or Service
b. Sub-Product or Sub-Service (optional)

(e.g., checking account)
(e.g., overdraft protection)

[CHECKBOX]

The web form uses “natural language processing” of the text entered in Item 2 to suggest possible
products and sub-products. Consumers have the option of checking “Other” and selecting from a
dropdown menu or entering text.
Prompts for Item 6 and Item 10 are driven by response to Item 5.
6. The issue with this product or service is: *
Please choose the issue(s) that best matches what you described.
a. Issue
(e.g., charged a fee)
b. Sub-Issue (optional)
(e.g., fee higher than expected)

[DROP DOWN]

The web form uses “natural language processing” of the text entered in Item 2 and the response to Item
5 to suggest possible issues and sub-issues. Consumers have the option of checking “Other” and selecting
from a dropdown menu or entering text.
7. When did this happen?

* Answers to these questions are necessary for CFPB take action

[DATE]
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Inventory of Questions for the Consumer Financial Protection Bureau’s
Consumer Response Intake Form (OMB No. 3170-0011)
8. If you have suffered a loss, Eestimate the total dollar value of your loss based on what you know right
now. [NUMBER]
9. What do you think would be a fair resolution of this issue? *
[TEXT]
The web form uses “natural language processing” of the text entered in Item 2 and response to Item 6 to
suggest possible resolutions. Consumers have the option of checking “Other” and selecting from a
dropdown menu or entering text.
10. I want to submit anonymously. I understand the CFPB may not be able to respond or take action.*
If yes, skip to Item 14.
[CHECKBOX]
If “Yes,” go to Item 14. Consumer will answer Items 14-15 and go to Submit.
11. I do not want the CFPB to send information about me to the company. I understand the CFPB may not
be able to take action.*
[CHECKBOX]
12. Do you have a loan or account number for this product? If yes, provide in Item 13.
If “No,” Item 13 is optional.

[CHECKBOX]

13. Account, Client Number, or other consumer identifying information for the company*[NUMBER or
TEXT]
We use this information to determine which company you are complaining about and to help make sure
the company reviews the correct account. The more information you provide, the faster we are able to
process this form and take action on this issue.
Fields in Item 13 are enabled based on relevance to product or service selected in Item 5. For most
products and services, only one field is needed. Social Security Number (SSN) and Individual Taxpayer
Identification Number (ITIN) will only be enabled for credit reporting complaints and debt collection since
the consumer’s SSN or ITIN is the only unique identifying number. For debt collection complaints, only the
last four of the SSN are asked.
Customer/Client Number
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SSN or ITIN
Account Number
Providing this information is optional. The CFPB
Loan Number
only uses this information to help make sure
Mortgage Loan Number
credit reporting agencies review the correct
Mortgage Loan Originator Unique ID
report.
Policy Number
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Credit and Prepaid Card Number
Property address
The CFPB only uses your card number to ensure
Billing address
we send information to the correct company.
We will never ask for your expiration date or
Transaction number
the security code on the back of your credit
Name and/or date of birth as appears
card.
on credit report
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Name as it appears on account
Checkbox to indicate when property and/or billing addresses are the same as mailing address
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14. Information about the Company *

* Answers to these questions are necessary for CFPB take action

[AUTO COMPLETE OR TEXT]
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Inventory of Questions for the Consumer Financial Protection Bureau’s
Consumer Response Intake Form (OMB No. 3170-0011)
Where a mortgage is selected in Item 5, Item 14 will ask for “Company You Should Send
Payments To: (Servicer)”.
Company Name *[AUTO COMPLETE OR TEXT], Company Type [DROP DOWN], Address [AUTO
COMPLETE OR TEXT], Address 2 [AUTO COMPLETE OR TEXT], City [AUTO COMPLETE OR TEXT],
State [AUTO COMPLETE OR TEXT], Zip Code [AUTO COMPLETE OR TEXT], Country [AUTO
COMPLETE OR TEXT], Phone [AUTO COMPLETE OR TEXT], Website [AUTO COMPLETE OR TEXT],
Email address [TEXT], Representative Name(s) or ID, Other Identifying Company Information
[TEXT], Name of Mobile App [TEXT]
[OPTION TO ADD ADDITIONAL COMPANIES]
15. Have you done any of these things to try to resolve this issue?
Check all that apply and provide details below.

[CHECKBOX]

e.g., hired an attorney, filed a legal action; contacted the company, a government agency, the
CFPB, the Better Business Bureau, etc. Also, if boxes are checked a text box will be provided to
give details.
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. [TEXT]
II. ABOUT THE CONSUMER
This “About the Consumer” section captures information about the consumer and, where applicable,
information about the individual filing the form.
16. I am filling out this form on behalf of: *

[CHECKBOX]

Myself (Go to 17)
Myself and Someone Else (Go to 18)
Someone Else
If “Someone Else” is selected the following message will appear: If you are filing on behalf of
someone else, please know that the CFPB may need this person’s signed, written permission to
take action on this issue. Additional instructions for sending this permission will be provided
after you submit this form.
a. What is your relationship to this person? *
[CHECKBOX and TEXT]
(e.g., Family Member, Friend, Legal Client, Congressional Constituent, Advocacy Client,
Community Service Organization Client, Housing Counseling Client, Other [TEXT])
Describe your relationship to this person.*
(e.g. if Advocacy Client is selected, the name of the advocacy organization)
b. Please tell us your name and contact information.
Name: Salutation [DROPDOWN], First Name [TEXT]*, Middle Name [TEXT], Last Name
[TEXT]*, Suffix [TEXT]
Mailing Address: Address [TEXT]*, Address 2 [TEXT], City [TEXT]*, State [TEXT]*, Zip
Code/APO/FPO [TEXT]*, Country [TEXT]*

* Answers to these questions are necessary for CFPB take action

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Inventory of Questions for the Consumer Financial Protection Bureau’s
Consumer Response Intake Form (OMB No. 3170-0011)

Other Contact Information: Phone [NUMBER]*, Is this a mobile phone? [CHECKBOX]*, Fax
[NUMBER], Email Address [TEXT]*
[CHECKBOX OPTION TO ADD ADDITIONAL CONTACT FIELDS]
[Checkbox option to indicate user does not have a specific piece of contact information (e.g.
email)]
17. [e.g., Account] Contact Information
Enter the name(s) and address associated with this [e.g., account].
Name [e.g., Accountholder Name(s), Consumer Name(s), etc.]: Salutation [DROPDOWN], First
Name [TEXT]*, Middle Name [TEXT], Last Name [TEXT]*, Suffix [TEXT]
Address: Address [TEXT]*, Address 2 [TEXT], City [TEXT]*, State [TEXT]*, Zip Code/APO/FPO
[TEXT]*, Country [TEXT]*, This is also the mailing address [CHECKBOX]
Other Contact Information: Phone [NUMBER]*, Is this a mobile phone? [CHECKBOX]*, Fax
[NUMBER], Email Address [TEXT]*
[CHECKBOX OPTION TO ADD ADDITIONAL CONTACT FIELDS]
[Checkbox option to indicate user does not have a specific piece of contact information (e.g.
email)]
18. Does this complaint involve an additional consumer?
(e.g. a joint account-holder, co-signer, co-borrower, an additional card holder, sender, recipient,
an additional account-holder, etc.) 3
Mailing Information for the additional consumer
Mailing Address is auto completed from Item 18 if box checked for “This is also the mailing
address”.
Name [e.g., Accountholder Name(s), Consumer Name(s), etc.]: Salutation [DROPDOWN], First
Name [TEXT]*, Middle Name [TEXT], Last Name [TEXT]*, Suffix [TEXT]
Address: Address [TEXT]*, Address 2 [TEXT], City [TEXT]*, State [TEXT]*, Zip Code/APO/FPO
[TEXT]*, Country [TEXT]*
Other Contact Information: Phone [NUMBER]*, Is this a mobile phone? [CHECKBOX]*, Fax
[NUMBER], Email Address [TEXT]*
Checkbox option to indicate it is the same as the complainant for jointly-submitted
complaints.
New question informed by usability testing under Generic Clearance for Consumer Complaint Information
Collection System (Testing and Feedback), OMB Control No. 3170-0042 (NOA 11/5/2013).

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* Answers to these questions are necessary for CFPB take action

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Inventory of Questions for the Consumer Financial Protection Bureau’s
Consumer Response Intake Form (OMB No. 3170-0011)

[CHECKBOX OPTION TO ADD ADDITIONAL CONTACT FIELDS]
[Checkbox option to indicate user does not have a specific piece of contact information (e.g.
email)]
19. Would you like to add an additional point of contact? [CHECKBOX]
If user would like to add an additional point of contact, go to item 16 and complete its subparts
for this user. 4
20. Other Contact Information and Communication Preferences
Phone Number [NUMBER], Is this a mobile phone? [CHECKBOX], Alternate Phone Number
[NUMBER], Is this a mobile phone? [CHECKBOX], Fax [NUMBER], Email Address [TEXT], Confirm
Email Address [TEXT]
[CHECKBOX OPTION TO ADD ADDITIONAL CONTACT FIELDS]
Best Way to Contact [CHECKBOX] (e.g., email, text, phone, mail, fax), Best Time to Contact
[DROPDOWN] (e.g., 8am - Noon ET, Noon - 4pm ET, 4pm - 7pm ET), Preferred Language
[DROPDOWN]
21. Create a Password and/or a PIN*
You can see the status of this complaint at www.consumerfinance.gov. Your username is [Email
address from Item 16-18 or if no email is provided a different username or unique identifier may
be used to log in]. Do not use the same password you use to log in to this email account. The
password must include at least one capital letter and a number or special character.
Create Password [TEXT] and/or PIN [NUMBER]
22. What is your age? ______

[NUMBER]

23. What affiliations apply to the complainant?
Check all that apply. [CHECKBOX]
Servicemember or veteran
Dependent of a servicemember or veteran
Current student
62 years old or older
A person with a disability
If servicemember or veteran or a dependent of a servicemember or veteran is selected:
Servicemember’s Name: Salutation [DROPDOWN], First Name [TEXT]*, Middle Name [TEXT],
Last Name [TEXT]*, Suffix [TEXT]
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Usability Testing

* Answers to these questions are necessary for CFPB take action

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Inventory of Questions for the Consumer Financial Protection Bureau’s
Consumer Response Intake Form (OMB No. 3170-0011)

Address: Is the servicemember’s address the same as mailing address already provided?
[CHECKBOX], Address [TEXT]*, Address 2 [TEXT], City [TEXT]*, State [TEXT]*, Zip
Code/APO/FPO [TEXT]*, Country [TEXT]*
What is the servicemember’s status? [DROP DOWN]*
What is the servicemember’s branch of service? [DROP DOWN]*
What is the servicemember’s rank? [DROP DOWN]
What is the servicemember’s installation? [DROP DOWN]
[CHECKBOX OPTION TO ADD ADDITIONAL SERVICEMEMBER CONTACT FIELDS]
24. If you are completing this form about a mortgage issue, please answer these questions.
In the web form, Item 24 and its subparts only appear when the response to Item 5 is mortgagerelated.
a. Are you concerned about losing your home to foreclosure?
If No, skip to Submit.

[CHECKBOX]

b. 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.
[CHECKBOX]
If “Yes”, continue to Item c.
If “No”, skip to Item d.
c. Is there a date that is scheduled for the foreclosure sale of your home? If a foreclosure sale
has been scheduled, you might have received a Notice of Sale or Order Setting Sale.
If “Yes”, continue to Item c.
[CHECKBOX]
If “No” or “Don’t Know”, skip to Item d.
i. If yes, what is the date of the scheduled foreclosure sale? Please provide
the exact date if you can. This should be on the Notice of Sale or the
Order Setting Sale.
[DATE] [CHECKBOX]
d. Some companies may charge homeowners a fee for services described as foreclosure
defense, foreclosure prevention, foreclosure rescue, or loss mitigation assistance. Did you
hire one of these companies to help you avoid foreclosure?
[CHECKBOX]
If “Yes”, then continue to Item g.
If “No” or “Don’t Know”, then skip to Submit.
e. If you hired a company to help you avoid foreclosure, what is the name of that
company? [TEXT]
25. If you are completing this form about a payday or consumer loan issue, please answer these
questions.
In the web form, Item 25 and its subparts only appear when the response to Item 5 is payday or
consumer loan-related (e.g. title or pawn loans).

* Answers to these questions are necessary for CFPB take action

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Inventory of Questions for the Consumer Financial Protection Bureau’s
Consumer Response Intake Form (OMB No. 3170-0011)
a. Where did you get the payday or consumer loan?
The user may indicate “In person / at a store (even if you applied online)” or “Online”
b. If “in person / at a store,” user is asked for the US state location
c. If “online,” the user is asked for the company’s website
26. If you are completing this form about a credit reporting issue, please answer these questions:
In the web form, Item 26 and its subparts only appear when the response to Item 5 is credit reporting
or when the a credit reporting issue is selected in Item 6.
a. Have you disputed the issue with the credit reporting company and received a final response?

b. If “YES,” what is the original dispute case number? [NUMBER]
c. I authorize and direct any credit reporting agency to furnish a copy of my consumer report to
the CFPB for the purpose of responding to and investigating my consumer complaint.*
[Checkbox]
d. Note, for a third party the authorization would add “This authorization must be
completed by the consumer for whom this complaint pertains and not the consumer’s
representative. Submission by anyone other than the consumer may be considered a
false statement and punishable by law.”
27. If you are completing this form about a money transfer issue, please answer these questions:
In the web form, Item 27 and its subparts only appear when the response to Item 5 is money transfer
a. Where did the transaction take place? [DROPDOWN]
The user may indicate “In person, phone, fax” or “Online”
b. If “in person, phone, fax” user is then asked for the company’s identifying information in
item 14 if not previously indicated by the user
c. If “online,” the user is asked for the company’s website or name of mobile app [TEXT}
d. How much was transferred? [NUMBER]
e. What is the date of transfer? [DATE]
f.

What is the funds promised date? [DATE]

g. What was the amount of error? [NUMBER]
h. What was the date the issue occurred? [DATE] [NUMBER]
i. How was the transfer received? [DROPDOWN]
(e.g. in person or home or deposited or credited into an account)

* Answers to these questions are necessary for CFPB take action

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Inventory of Questions for the Consumer Financial Protection Bureau’s
Consumer Response Intake Form (OMB No. 3170-0011)

j.

For either option, user is then asked for the company’s identifying information in item
14 if not previously indicated by the user

28. If you are completing this form about a student loan issue, please answer these questions:
In the web form, Item 28 and its subparts only appear when the response to Item 5 is related to a
student loan.
a. What college or university did you attend when you received the loan(s)?
[DROPDOWN]
29. If you are completing this form about a vehicle loan or lease issue, please answer these
questions:
In the web form, Item 29 and its subparts only appear when the response to Item 5 is vehicle loan or
lease
a. What is the type of vehicle? (e.g. new or use) [DROPDOWN]
b. Where did you receive your vehicle financing? (e.g. dealership, bank, lender or
financing company).
c. If dealership, what is the name of the dealership? [TEXT] and state [DROPDOWN]
30. Consent to Publish What Happened in the Complaint Database
Information about financial products and services is collected to improve the financial products
marketplace. The subject, date of the complaint and the company’s response may be published in
the Complaint Database for researchers, journalists, and the public. All personal information, such as
names, contact information, account numbers, social security numbers, and supporting documents
will be removed before publishing.
31. Security Questions*
The user is asked a series of randomized security questions at the end of the complaint form for
purposes of authenticating the user. This information will be used to verify a return submitter and to
grant the user future access to the complaint’s details and company’s response, including by web or
phone.
32. Captcha*
To prevent abuse of the complaint system by automated programs and other high-frequency users,
a captcha consisting of a series of randomized characters may be added in certain cases for human
verification purposes.
III. SUBMIT
Consumers will have an opportunity to view and edit all responses before submitting and will check a
box indicating that they understand CFPB cannot act as their personal lawyer and cannot give legal
advice and affirm that the information provided is true and complete to the best of their knowledge.
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. *
[CHECKBOX]

* Answers to these questions are necessary for CFPB take action

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Inventory of Questions for the Consumer Financial Protection Bureau’s
Consumer Response Intake Form (OMB No. 3170-0011)

IV. DOCUMENTS [POST-SUBMISSION, OPTIONAL AT INTAKE]
If you want to attach documents to send to the company to support your complaint or to help us
investigate this issue, please indicate how you would like to provide this documentation. Please note
that because of the number of complaints we receive, we may not be able to review all the
documents submitted.
[CHECKBOX]
To upload documents, attach here. If uploading documents, please provide a brief description of
the documents. [TEXT]
To email documents, click here for template and email address.
To submit documents by fax, click here to download print a fax coversheet.
To submit documents by mail, click here to download and print a cover letter and for the CFPB’s
complaint mailing address. Do not send original documents.
Privacy Act Statement
The information that you provide will permit the Consumer Financial Protection Bureau to respond to
consumer complaints and inquiries regarding practices by banks and other institutions supervised by the
Consumer Financial Protection Bureau. The information may be disclosed:
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•
•
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•

to an entity that is the subject of a complaint or inquiry;
to a court, magistrate or administrative tribunal in the course of a proceeding;
to third parties to the extent necessary to obtain information that is relevant to the resolution of
a complaint or inquiry;
for enforcement, statutory, and regulatory purposes;
to another federal or state agency or regulatory authority;
to a member of Congress; to the Department of Justice, a court, an adjudicative body or
administrative tribunal, or a party in litigation; and
to contractors, agents, and others.

This collection of information is authorized by 12 U.S.C. § 5493.
You are not required to file a complaint or inquiry and you may withdraw your complaint or inquiry at
any time. However, if you do so, the Consumer Financial Protection Bureau may not be able to
investigate your complaint or inquiry.
Notice of Consumer Information Collection
An agency may not conduct or sponsor, and a person in not required to respond to, a collection of
information unless the collection of information displays a valid control number assigned by the Office
of Management and Budget (OMB). The OMB control number for this collection is 3170-0011. This
collection expires on XX/XX/XXXX.

* Answers to these questions are necessary for CFPB take action

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Inventory of Questions for the Consumer Financial Protection Bureau’s
Consumer Response Intake Form (OMB No. 3170-0011)

Privacy Act Statement
The information that you provide will permit the Consumer Financial Protection Bureau to respond to
consumer complaints and inquiries regarding practices by banks and other institutions supervised by the
Consumer Financial Protection Bureau. The information may be disclosed:
•
•
•
•
•
•
•

to an entity that is the subject of a complaint or inquiry;
to a court, magistrate or administrative tribunal in the course of a proceeding;
to third parties to the extent necessary to obtain information that is relevant to the resolution of
a complaint or inquiry;
for enforcement, statutory, and regulatory purposes;
to another federal or state agency or regulatory authority;
to a member of Congress; to the Department of Justice, a court, an adjudicative body or
administrative tribunal, or a party in litigation; and
to contractors, agents, and others.

This collection of information is authorized by 12 U.S.C. § 5493.
You are not required to file a complaint or inquiry and you may withdraw your complaint or inquiry at
any time. However, if you do so, the Consumer Financial Protection Bureau may not be able to
investigate your complaint or inquiry.
Notice of Consumer Information Collection
An agency may not conduct or sponsor, and a person in not required to respond to, a collection of
information unless the collection of information displays a valid control number assigned by the Office
of Management and Budget (OMB). The OMB control number for this collection is 3170-0011. This
collection expires on XX/XX/XXXX.

* Answers to these questions are necessary for CFPB take action

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