Consumer Response Customer Survey

Company Response Survey (Paper Form)
!
!

Provide!feedback!about!the!company’s!
response!to!your!complaint.!
!
[INSERT:!!DATE]!
!
[INSERT:![CONTACT’S!FULL!NAME]!
[INSERT:!CONTACT’S!ADDRESS!1]!
[INSERT:!CONTACT’S!ADDRESS!2]!
[INSERT:!CONTACT’S!CITY],![CONTACT’S!STATE]![CONTACT’S!ZIP]!
!
Dear![INSERT:!CONSUMER!FIRST!NAME!LAST!NAME],!
Thank!you!for!contacting!the!Consumer!Financial!Protection!Bureau.!When!you!called!about!the!company’s!response!to!
your!complaint!you!requested!a!paper!feedback!form.!The!feedback!form!and!instructions!are!included!with!this!letter.!
You!have!60#days!from!when!the!company!sent!their!response!to!complete!and!return!your!feedback!form.##

#
You#can#return#your#feedback#by:#
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Mail:!

Consumer!Financial!Protection!Bureau!
P.O.!Box!4503!
Iowa!City,!IA!52244!
!
Fax:!(855)!237]2392!!

!
We!appreciate!your!participation!in!the!complaint!process.!
!
Thank!you,!!
!
Consumer!Financial!Protection!Bureau!
consumerfinance.gov!
(855)!411]2372!
!

QUICK!LINKS!

More%about%our%complaint%process:%consumerfinance.gov/complaint/%or%call%(855)%411=2372!
For%legal%assistance%visit%the%Legal%Services%Corporation%website:!lsc.gov!%
Additional%financial%information%and%resources:%%consumerfinance.gov%%
%

Submit your feedback on
the company response

OMB NO. 3170-XXXX
EXPIRATION DATE: [XX/XX/XXXX]

Name: [Consumer First name Last name]
Complaint Id: [Complaint number]

You will have 60 days from when the company
responds to complete your feedback.
The CFPB will share your feedback responses with the company and use the
information to help the CFPB’s work with consumer complaints. Participation is
voluntary, you are not required to submit feedback.

How to submit this feedback form

Other ways to submit feedback

By fax
(855) 237-2392

Over the phone
(855) 411-2372

By mail
Consumer Financial Protection Bureau
PO Box 4503
Iowa City, IA 52244

Online
consumerfinance.gov/complaint

Consumer Financial
Protection Bureau

SUBMIT YOUR FEEDBACK ON THE COMPANY RESPONSE

Submit your feedback
Only provide feedback about the response that you received from the company.

1

The company’s response addressed all of my issues.

Yes

No

Yes

No

Yes

No

Please provide any
additional comments to
explain your response.
(Optional)

Do not include personal
information, such as your name,
account number, address, Social
Security number, etc.

2

I understand the company’s response to my complaint.
Please provide any
additional comments to
explain your response.
(Optional)

Do not include personal
information, such as your name,
account number, address, Social
Security number, etc.

3

The company did what they said they would do with my complaint.
Please provide any
additional comments to
explain your response.
(Optional)

Do not include personal
information, such as your name,
account number, address, Social
Security number, etc.

For help with this form call (855) 411-2372

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SUBMIT A COMPL AINT ABOUT A FINANCIAL PRODUCT OR SERVICE

Paperwork Reduction Act
CFPB will treat the information received consistent with its confidentiality regulations at 12 C.F.R. Part 1070, et seq.
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 study is 3170-XXXX. The control number expires on XX/XX/XXXX. The estimated time to complete
this survey is about 5 minutes. If you have any comments regarding the time estimates associated with this study or
suggestions on making this process simpler, please contact the Consumer Financial Protection Bureau (Attention:
PRA Office), 1700 G Street NW., Washington, DC 20552; 202-435-9575; or [email protected].

Privacy Act Statement
5 U.S.C. 552a(e)(3)
The information you provide through your participation in the Company Response Survey will provide valuable
feedback to the company about how they handled your complaint. Your answers to this survey will be available to
the company. If you have provided consent, the CFPB may publish your de-identified responses on the Consumer
Complaint Database.
The Consumer Financial Protection Bureau (“CFPB”) will use your responses to inform CFPB’s work.
Information collected by the CFPB will be treated in accordance with the System of Records Notice (“SORN”),
CFPB.022 – Market and Consumer Research Records, https://www.federalregister.gov/articles /2012/11/14/201227582/privacy-act-of-1974-as-amended. This collection of information is authorized by Pub. L. No. 111-203, Title X,
Sections 1013 and 1022, codified at 12 U.S.C. §§ 5493 and 5512.
Participation in this survey is voluntary. You are not required to participate.

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.

I want the CFPB to publish this feedback on consumerfinance.gov so that others can learn
from my experience.

Consumer Financial
Protection Bureau

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