BOARDING FORM: CFPB Congressional Portal

BOARDING FORM

 CFPB Congressional Portal

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

To access consumer complaints submitted by your office on behalf of your
constituents using the Congressional Portal, you are required to complete and
submit this form to [email protected]. The information you
provide enables us to set up your office’s access to the Congressional Portal.
Privacy release:
In addition to the completed CFPB Congressional Portal boarding form, a privacy
release form signed by the consumer must be provided.

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 consumer complaints submitted by your office on behalf of constituents
to the CFPB’s Office of Consumer Response. Account access to the web-based Congressional 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 Congressional 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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CONGRESSIONAL BOARDING FORM

Office information

1

NAME OF MEMBER OF CONGRESS

LEGISLATIVE BODY

STATE

DISTRICT

Contact information
The authorized employee will be the main point of contact for the CFPB Congressional 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
Providing the following information enables us to set up the user profiles for each authorized user.

3

Is the authorized employee (from Section 2) the only authorized Congressional
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.
Email this completed form to [email protected] to request access to the
Congressional Portal.

For Internal Use Only (For internal use only)

Consumer Financial
Protection Bureau

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CONGRESSIONAL 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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