BOARDING FORM: CFPB Government Portal

BOARDING FORM

 CFPB Government Portal

OMB No. 3170-00XX
Expiration Date: XX/XX/XXXX

In order to gain access to the Consumer Financial Protection Bureau (CFPB)
Government Portal, you will need to submit this registration form. The information
requested will help us to set up your portal access for any agency employee you
submit on this form. Once you have completed the form, you may submit it by
emailing to [email protected].

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 access the web-based Government Portal for the CFPB’s Office of Consumer
Response. Account access to the web-based Government Portal will enable you to view the complaints or
inquiries. The information you provide may be shared:
§§ 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;
§§ To the public, members of the media, federal, state, and local government officials, or other recipients
of public relations materials issued by the CFPB about the activities of the CFPB; and
§§ Pursuant to the CFPB’s published Privacy Act System of records notice, CFPB.005- Consumer
Response System.
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 Government 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

Consumer Financial
Protection Bureau

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GOVERNMENT BOARDING FORM

Agency information

1

AGENCY STATE

AGENCY NAME

Contact information
The authorized employee will be the main point of contact for the CFPB Government Portal and will be the
only person authorized to add or remove users.

2

NAME OF AUTHORIZED EMPLOYEE

TITLE

EMAIL

PHONE NUMBER

STREET

CITY

STATE

ZIP CODE

Portal Users Information
The following information is needed to set up the user profiles for each authorized individual.

3

Is the authorized employee (from Section 2) the only authorized Government
Portal user in your office?

Consumer Financial
Protection Bureau

YES

NO

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Portal Users Information (continued)

4

If ‘NO’ complete
this section for
each authorized
user.

NAME OF AUTHORIZED USER

TITLE

EMAIL

PHONE NUMBER

NAME OF AUTHORIZED USER

TITLE

EMAIL

PHONE NUMBER

NAME OF AUTHORIZED USER

TITLE

EMAIL

PHONE NUMBER

Submit

5

By clicking this box, you affirm that the information provided is true to the best of your
knowledge and belief.

For Internal Use Only (For internal use only)

Consumer Financial
Protection Bureau

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GOVERNMENT BOARDING FORM

Addendum

6

If you need to
register additional
users, please enter
them here.

NAME OF AUTHORIZED USER

TITLE

EMAIL

PHONE NUMBER

NAME OF AUTHORIZED USER

TITLE

EMAIL

PHONE NUMBER

NAME OF AUTHORIZED USER

TITLE

EMAIL

PHONE NUMBER

NAME OF AUTHORIZED USER

TITLE

EMAIL

PHONE NUMBER

NAME OF AUTHORIZED USER

TITLE

EMAIL

PHONE NUMBER

Consumer Financial
Protection Bureau

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GOVERNMENT BOARDING FORM

Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person
is not required to respond to a collection of information unless it displays a valid OMB control number.
The OMB control number for this collection is 3170-XXXX. It expires on MM/DD/YYYY. The time required
to complete this information collection is estimated to average approximately 15 minutes per response.
The obligation to respond to this collection of information is voluntary: however if you do not include the
requested information you may not be granted access to the congressional/government portal. Comments
regarding this collection of information, including the estimated response time, suggestions for improving
the usefulness of the information, or suggestions for reducing the burden to respond to this collection should
be submitted to Bureau at the Consumer Financial Protection Bureau (Attention: PRA Office), 1700 G Street
NW, Washington, DC 20552, or by email to [email protected].

Consumer Financial
Protection Bureau

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