Consumer Response Intake Forms

OMB Control Number: 3170-0011
Expiration Date: XX/XX/XXXX

Inventory of Questions for the Consumer Financial Protection Bureau’s
Consumer Response Intake Form

INSTRUCTIONS
I.

ABOUT THE ISSUE
This section is designed to capture information needed to investigate and respond to complaints.
1. What is this complaint about?* Choose the product or service that best matches your
complaint.
[RADIO BUTTON]
a. Product or Service
b. Sub-Product or Sub-Service (optional)

(e.g., student loan)
(e.g., private student loan)

Prompts for Item 2 are driven by response to Item 1.
2. What type of problem are you having?* Select the one that best describes your complaint.
[RADIO BUTTON]
a. Issue
b. Sub-Issue (optional)

(e.g., getting a loan)
(e.g., denied loan)

The web form uses the response to Item 1 to suggest possible issues and sub-issues.
3. Have you already tried to fix this problem with the company?*

[RADIO BUTTON]

a. Yes
b. No
4. What happened?* Describe what happened, and we’ll send your comments to the companies
involved.
[TEXT]
•
•

Include dates, amounts, and actions that were taken by you or the company
Do not include personal information, such as your name, account number, address, Social
Security number, etc. We may ask for some of this information later, to help the company
identify you and your account.

5. I want the CFPB to publish this description on consumerfinance.gov so that others can learn from my
experience. The CFPB will take steps to remove my personal information from this description but
someone may still be able to identify me. Learn how it works [HYPERLINK]. I consent to publishing
this description after the CFPB has taken these steps. Publishing this description will not affect how
the CFPB handles your complaint.
[CHECKBOX]
6. What would be a fair resolution to this issue?* We’ll forward this to the companies involved. Be
specific so they know what resolution you are looking for. The company may or may not offer to resolve
your complaint.
[TEXT}

* Answers to these questions are necessary for the CFPB to take action.

1

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

7. Attach documents Include copies or photos of documents related to your issue, such as contracts,
letters, and receipts, and we will forward all materials to the company for review.
•

Select a file to attach. We accept all file formats, except .dll, .dmg, .exe and .msi, up to 10 MB per
file. All uploaded files will be scanned for viruses and will be immediately deleted if one is detected.

8. What company is this complaint about?* We’ll forward your entire complaint to the company and
request they respond within 15 days of receiving it.
[AUTO COMPLETE OR TEXT]
If the user-entered company name is not in the system, the user is prompted to provide addition
information in the following optional text fields:
• Other names for this company
• Company country [PICKLIST]
• Company address line 1
• Company address line 2
• City
• State
• ZIP code
• Website
• Phone number
• Other identifying characteristics
9. Please provide as much information as you want to share to help the company find you in their
system and respond to your complaint.
[NUMBER or TEXT]
Fields in Item 9 are enabled based on relevance to product or service selected in Item 1. All fields are
optional. Full social security number (SSN) will only be enabled for student loan complaints since the
consumer’s SSN is the most reliable unique identifying number. For credit reporting and debt collection
complaints, only the last four digits of the SSN are asked.
•
•
•
•

Account Number
Loan Number
Billing address
Name as it appears on credit report

•
•
•

Date of birth
SSN or last four digits of SSN
Card Number

II. ABOUT THE CONSUMER
This section captures information about the consumer(s) and, where applicable, information about
the individual filing the form if it is someone other than the affected consumer.
10. Who are the people involved?* Identify who is involved in this complaint. This could include
yourself, a co-borrower, or someone helping submit the complaint for you, such as a lawyer, an
advocate, or a family member.
[RADIO BUTTON]
•
•
•

Just you
You and someone else
Someone else

* Answers to these questions are necessary for the CFPB to take action.

2

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

11. Your contact information
The above text changes to state “Their contact information” if the user selects “Someone else” in
item 10.
•

First Name* [TEXT], Middle Name [TEXT], Last Name* [TEXT], Suffix [PICKLIST ]

•

Country* [PICKLIST], Address line 1* [TEXT], Address line 2 [TEXT], City* [TEXT], State*
[PICKLIST], ZIP or postal code* [TEXT]

•

Other contact information: Age [NUMBER], Phone number [NUMBER], Email* [TEXT], You
don’t have an email address [CHECKBOX]
If the user indicates they do not have an email address, the email field is no longer required
and the phone number field becomes required. This is to ensure an appropriate amount of
identifying information is captured on the web form to validate consumers when they call
the contact center.

For mortgage complaints:
•

What is the address of the mortgage property?
Same as mailing address [CHECKBOX]
If the mortgage address is different than the mailing address, the user is provided with the
following fields:

•

Country [PICKLIST]*, Address line 1* [TEXT], Address line 2 [TEXT], City* [TEXT], State*
[PICKLIST], ZIP or postal code* [TEXT]

For credit card complaints:
•

What is the billing address for the credit card?
Same as mailing address [CHECKBOX]
If the billing address for the credit card is different than the mailing address, the user is
provided with the following fields:

•

Country [PICKLIST]*, Address line 1* [TEXT], Address line 2 [TEXT], City* [TEXT], State*
[PICKLIST], ZIP or postal code* [TEXT]

•

What affiliations does the primary consumer have? Choose all that apply. [CHECKBOX]
o
o

A servicemember or veteran
A spouse or dependent of a servicemember or veteran

If servicemember or veteran or a dependent of a servicemember or veteran is selected:

* Answers to these questions are necessary for the CFPB to take action.

3

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

Current status*
Branch of service*
Rank
Military base/location

[PICKLIST]
[PICKLIST]
[PICKLIST]
[PICKLIST]

•

How many people (total number of adults and children) are part of the primary
consumer’s household? [PICKLIST]

•

What is the total combined income of all the people living in the primary consumer’s
household in the last twelve months? [PICKLIST]

12. Additional person’s information
• Does this complaint involve someone else?*
o
o

[RADIO BUTTON]

Yes
No

•

If yes, How is this person involved in the complaint?*
[PICKLIST]
o Picklist values are enabled based on relevance to product or service selected in Item
1 (e.g., Co-signer, Co-borrower, Additional account holder)

•

First Name* [TEXT], Middle Name [TEXT], Last Name* [TEXT], Suffix [PICKLIST]

•

Allow this person to access this complaint and receive status updates.

•

Country* [PICKLIST], Address line 1* [TEXT], Address line 2 [TEXT], City* [TEXT], State*
[PICKLIST], ZIP or postal code* [TEXT]

•

Other contact information: Age [NUMBER], Phone number [NUMBER], Email* [TEXT], They
don’t have an email address [CHECKBOX]

[CHECKBOX]

If the user indicates the additional person does not have an email address, the email field is
no longer required and the phone number field becomes required. This is to ensure an
appropriate amount of identifying information is captured on the web form to validate
consumers when they call the contact center.
13. Additional point of contact
• Should we send status updates to anyone else about this complaint? [RADIO BUTTON]
o
o
•

Yes
No

If yes, Relationship to you*
[PICKLIST]
o Picklist values include: Advocate, Attorney, Family member, Friend, Government
employee, Housing counselor, Other. For all selections, other than Friend, an
optional text box is provided for additional detail (e.g., if Attorney is selected “Law
firm or practice” is the field provided).

* Answers to these questions are necessary for the CFPB to take action.

4

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

•

First Name* [TEXT], Middle Name [TEXT], Last Name* [TEXT], Suffix PICKLIST]

•

Allow this person to access this complaint and receive status updates.

•

Country* [PICKLIST], Address line 1* [TEXT], Address line 2 [TEXT], City* [TEXT], State*
[PICKLIST], ZIP or postal code* [TEXT]

•

Other contact information: Age [NUMBER], Phone number [NUMBER], Email* [TEXT], They
don’t have an email address [CHECKBOX]

[CHECKBOX]

If the user indicates the additional person does not have an email address, the email field is
no longer required and the phone number field becomes required. This is to ensure an
appropriate amount of identifying information is captured on the web form to validate
individuals when they call the contact center.
14. If you are completing this form about a mortgage issue, please answer these questions.
On the web form, Item 14 and its subparts only appear when the response to Item 1 is Mortgage.
a. Please specify*
[TEXT]
• This field only appears when the user selects Mortgage as their product and Other as
their sub-product.
b. Are you concerned about losing your home to foreclosure?
[RADIO BUTTON]
• If Yes, skip to item c
• If No, skip to item e
• This field only appears when the user indicates their issue is either Trouble during the
payment process or Struggling to pay mortgage
c. Did you pay a company to help you avoid foreclosure?
• If Yes, then continue to item d
• If No, proceed to next page
d. What is the name of the company you paid to avoid foreclosure?

[RADIO BUTTON]

[TEXT]

e. 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.
[RADIO BUTTON]
• If Yes, continue to Item f
• If No, proceed to next page
f.

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.
[RADIO BUTTON]
• If Yes, continue to item g
• If No, proceed to the next page

* Answers to these questions are necessary for the CFPB to take action.

5

Inventory of Questions for the Consumer Financial Protection Bureau’s
Consumer Response Intake Form (OMB No. 3170-0011)
g. When is the scheduled foreclosure sale?

[DATE]

15. If you are completing this form about a payday loan, title loan, or personal loan issue, please
answer these questions.
On the web form, Item 15 and its subparts only appear when the response to Item 1 is Payday
loan, title loan, or personal loan.
a. Where did you get the loan?
[RADIO BUTTON]
The user may indicate “Online” or “In-person/at a store (even if you applied online)”
b. If “Online,” the user is asked for the company’s website

[TEXT]

c. If “In-person/at a store,” user is asked for the US state where the store is located

[TEXT]

16. If you are completing this form about a credit reporting issue, please answer these questions:
In the web form, Item 16 and its subparts only appear when the response to Item 1 is Credit
reporting or when a credit reporting issue is selected in Item 2.
a. Do you want to add an additional credit reporting company to this complaint?
[RADIO BUTTON]
b. If “Yes,” the consumer is prompted to answer questions 3, 8, and 9

[RADIO BUTTON] [TEXT]

c. I authorize and direct any consumer 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]
17. If you are completing this form about a credit card or prepaid card issue, please answer these
questions:
In the web form, item 17 and its subparts only appear when the response to item 1 is Generalpurpose prepaid card or Student prepaid card
a. (If General-purpose prepaid card is selected) Is your paycheck or government benefit
payment automatically loaded onto the card (often called "direct deposit")?*
[RADIO BUTTON]
b. (If Student prepaid card is selected) Is your student loan automatically loaded onto the
card?*
[RADIO BUTTON]
18. If you are completing this form about a vehicle loan or lease issue, please answer these
questions:
In the web form, Item 18 and its subparts only appear when the response to Item 1 is vehicle
loan or lease
a. (If vehicle loan is selected) Was the loan for a new or used vehicle?* [RADIO BUTTON]
b. (If vehicle lease is selected) Was the lease for a new or used vehicle?* [RADIO BUTTON]

* Answers to these questions are necessary for the CFPB to take action.

6

Inventory of Questions for the Consumer Financial Protection Bureau’s
Consumer Response Intake Form (OMB No. 3170-0011)
19. If you are completing this form about a student loan issue, please answer these questions:
In the web form, Item 19 and its subparts only appear when the response to Item 1 is related to a
Student loan.
a. What school were you attending when you got the loan?
[PICKLIST]
20. If you are completing this form about a money transfer issue, please answer these questions:
In the web form, Item 20 and its subparts only appear when the response to Item 2 is Mobile or
digital wallet
a. Are you able to store a balance in the digital wallet account that lets you add or withdraw
funds to use for purchases or payments?*
[RADIO BUTTON]
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]
Privacy Act Statement
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 submit 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.
Paperwork Reduction Act Statement

* Answers to these questions are necessary for the CFPB to take action.

7

Inventory of Questions for the Consumer Financial Protection Bureau’s
Consumer Response Intake Form (OMB No. 3170-0011)
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and not
withstanding any other provision of law 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 3170-0011. It expires on XX/XX/XXXX. The time required to complete this information
collection is estimated to average approximately 10 minutes per response. 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 the Bureau at the Consumer Financial Protection Bureau (Attention: PRA
Office), 1700 G Street NW, Washington, DC 20552, or by email to [email protected].

* Answers to these questions are necessary for the CFPB to take action.

8