CFPB Company Portal Boarding Form

Consumer Complaint Intake System Company Portal Boarding Form Information Collection System

Consumer Response's Company Portal Boarding Form (OMB FINAL) 7-10-2015

Consumer Response Company Boarding Form

OMB: 3170-0054

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3170-0054 can be found here:

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Notice of Collection under the Privacy Act of 1974, 5 U.S.C. § 552a
As Amended (Privacy Act Notice)
The information that you provide to the Consumer Financial Protection Bureau (CFPB) will be used to create a user account
so that you may log on to the web-based company portal for the CFPB’s Office of Consumer Response. Account access to
the web-based company portal will enable you to view complaints or inquiries filed against your company with the CFPB
and allow you to respond to the complaints or inquiries. The information you provide may be shared:

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to a court, magistrate, or administrative tribunal in the course of a proceeding;
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
pursuant to the CFPB’s published Privacy Act System of records notice, CFPB.005- Consumer Response System.

We may also share the response you submit regarding your company and its business activities (but not personally
identifiable information) with the public through the Public Complaint Database.
You are not required to submit or provide any identifying information; however, if you do not include the requested
information you may not be granted access to the company portal.
The collection of information is authorized by Public Law III-203, Title X, Sections 1011, 1012, 1013 (b)(3), 1021, 1034,
codified at 12 U.S.C. 5491, 5492, 5493(b)(3), 5511, 5534.

CFPB Company Portal
Boarding Form
To allow your company access to the consumer complaints submitted against it through the
Consumer Financial Protection Bureau (CFPB), complete the required sections of this form. The
information requested will help us to set up your company portal, provide access to the portal
for any company-authorized individual, and to route complaints efficiently to your portal. Once
you have completed the form you may submit the form by emailing the form to:
[email protected]

Section A: Company Information

This section is required. Please fill out the information in this section as it relates to your
company.

Enter the full name of your company:

Indicate the business structure of your company:
 Corporation
 Limited Liability Company
 Partnership
 S Corporation

Click here to enter text.

Approved for use through MM/DD/YYYY by OMB Control No. 3170-00XX

 Sole Proprietorship
3.

Enter your company’s tax ID:

Enter your company’s Financial Institution Number (FIN) (if your company does not have a FIN, list “N/A”):

5.
6.

Click here to enter text.
Click here to enter text.

Please list your company’s URL or website:

Click here to enter text.

Is this a web-based business (a web-based business is a business whose products or services are offered only
through the internet)?
 Yes
 No
7. Please list the mailing address of your company’s headquarters (this should NOT be a P.O. Box):
Street Address:
City:

Click here to enter text.

State:

Zip:

Choose an item.

Click here to enter text.

Does this address also reflect your state of incorporation or home state of business?
 Yes (If “Yes,” skip to question 11)
 No
ANSWER THIS QUESTION ONLY IF YOU ANSWERED “No” TO QUESTION 8
9. Please select the state of incorporation or home state of business for your company:

Choose an item.

10. Please list any state business licenses your company has and indicate the state for which the license is valid:
(If you need more rows than listed, please use the additional sheets at the end of the form or as an attachment.)
State Business License Number:
State for which the license is valid:

11. Is your company or a portion of your company owned by another company, often referred to as a parent
company?
 Yes
 No
ANSWER THESE QUESTIONS ONLY IF YOU ANSWERED “Yes” TO QUESTION 11
11a. Please enter the full name of your parent company:

Click here to enter text.

11b. Please list a point of contact (POC) for your parent company:

Click here to enter text.

11c. Please list a contact phone number or email address for the POC:

Click here to enter text.

Approved for use through MM/DD/YYYY by OMB Control No. 3170-00XX

Section B: Contact Information

This section is required. The authorized company officer or their designee will be the main
point of contact for the CFPB and will be the only authorized personnel to add or remove users
from the company portal maintained by the CFPB.

12. Please list the full name of the authorized officer/employee:

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13. Please list the title of the authorized officer/employee:

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14. Please list the phone number of the authorized officer/employee:

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15. Please list the email of the authorized officer/employee:

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16. If the authorized officer/employee is unavailable, please list the full name of the official designee:

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17. Please list the email of the official designee:

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18. Please list the phone number of the official designee:

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Section C: Portal Users Information

This section is required. The following information is needed to setup the user profiles for each
company-authorized individual. Enter the information necessary for all users that need access
to the company portal. Please provide information on each person you designate as a user.

19. Are the authorized officer/employee (from Section B) and designee, if named, the only portal users?
 Yes
 No (If “No,” please fill out the following section for each portal user.)
ANSWER THESE QUESTIONS ONLY IF YOU ANSWERED “No” TO QUESTION 19
Portal User 1:
First and Last Name:
Title/Position:

Click here to enter text.

Phone number:

Email:

Will this person need to export data into Excel or some other file?
 Yes
 No
Would you like to designate this person to submit portal servicing tickets?
 Yes
 No
Portal User 2:
First and Last Name:
Title/Position:

Click here to enter text.

Phone number:

Email:

Will this person need to export data into Excel or some other file?
 Yes
 No

Approved for use through MM/DD/YYYY by OMB Control No. 3170-00XX

Would you like to designate this person to submit portal servicing tickets?
 Yes
 No
Portal User 3:
First and Last Name:
Title/Position:

Click here to enter text.

Phone number:

Email:

Will this person need to export data into Excel or some other file?
 Yes
 No
Would you like to designate this person to submit portal servicing tickets?
 Yes
 No
Portal User 4:
First and Last Name:
Title/Position:

Click here to enter text.

Phone number:

Email:

Will this person need to export data into Excel or some other file?
 Yes
 No
Would you like to designate this person to submit portal servicing tickets?
 Yes
 No
Portal User 5:
First and Last Name:
Title/Position:

Click here to enter text.

Phone number:

Email:

Will this person need to export data into Excel or some other file?
 Yes
 No
Would you like to designate this person to submit portal servicing tickets?
 Yes
 No

Section D: Affiliates and Subsidiaries Information

This section is required. The following information is needed to effectively route consumer
complaints against affiliates and subsidiaries.

20. Does your company have any affiliates or subsidiaries?
 Yes (If “Yes,” please fill out the section below for each affiliate or subsidiary.)
 No
ANSWER THESE QUESTION ONLY IF YOU HAVE ANSWERED “Yes” TO QUESTION 20
Please only list subsidiaries and affiliates that provide consumer financial products or services, and whose
businesses would impact CFPB’s routing of consumer complaints.
Affiliate or Subsidiary Information:
Name of Affiliate or Subsidiary:
Tax ID of Affiliate or Subsidiary:

Approved for use through MM/DD/YYYY by OMB Control No. 3170-00XX

Click here to enter text.

Please list any information regarding the state business licenses for the affiliate:
State Business License Number
State for which it is valid
Entity or individual for which it is registered