Customer Complaint Form

OMB Control No. 1557-0232

Expiration Date: 10/31/2018

^{CUSTOMER COMPLAINT FORM}

^{Please fill in this form completely. Mail or fax this completed complaint form to:}

^{Office of the Comptroller of the Currency}

^{Customer Assistance Group}

^{1301 McKinney Street, Suite 3450}

^{Houston, TX 77010-9050}

^{1-713-336-4301 (Fax)}

^{Once we receive your completed form, you will receive an acknowledgment letter containing your assigned case number. Please keep your case number for future contact with our office.}

^{Helpful Hints:}

^{Check to make sure your financial institution is a national bank or federal savings association (thrift). If you do not know the name of your financial institution, check your account statement. The financial institution’s name will be indicated on the account statement.}

^{Have you tried to resolve your complaint with your financial institution? The OCC recommends that you attempt to resolve your complaint with your financial institution first. Please contact your financial institution to allow them the opportunity to resolve your issue(s).}

^{If your complaint involves more than one financial institution, you will need to submit a separate complaint form for each financial institution involved. You will receive separate case numbers for each financial institution.}

^{Please Note:}

• ^{We cannot act as a court of law or as a lawyer on your behalf}

• ^{We cannot give you legal advice}

• ^{We cannot become involved in complaints that are in litigation or have been litigated}

^{Your Information}

^{The Account Owner/Holder should complete this section. * - Indicates Required Fields}

*First Name:	Middle Name:
*Last Name:
*Street Address:
*City:		*State:	*Zip:
*Phone:
Email:
What is the best way to contact you? Phone Mail Email
What is the best time to contact you? Morning Afternoon Evening

^{Representative Contact Information}

^{If you want us to communicate with your attorney or other legal representative directly, please provide the information below. Your submission of this portion of the form authorizes your financial institution and our office to release information to your attorney or other legal representative, if requested. Please check the following to indicate the type of relationship:}

Attorney Legal Representative

^{Please indicate the type of authorization you have granted to your attorney or other legal representative:}

Power of Attorney Letters Testamentary Court Appointed Executor or Administrator

Other

^{If you are not sure of the type of legal authorization granted, please check your legal documents or consult with your attorney or other legal representative.}

^{Name of Representative:}

*First Name:	Middle Name:
*Last Name:
*Street Address:
*City:		*State:	*Zip:
*Phone:
Representative Email:
What is the best way to contact your representative? Phone Mail Email
What is the best time to contact your representative? Morning Afternoon Evening

^{Financial Institution or Company Information that is subject of the complaint}

^{Helpful Hint: If you do not know the name of your financial institution, check your account statement. The financial institution’s name will be indicated on the account statement.}

*Name of Financial Institution or Company:
Street Address:
*City:			*State:	Zip:
Phone:
*Type of Account(s) (Check all that apply): Deposit Account (Checking, Savings): Credit Card Insurance Mortgage
Loan Product (Consumer, Mortgage, Home Equity): Asset Management (Trust Accounts):
Consumer Leasing: Non-Deposit Account (Investments): Insurance: Other:
Have you tried to resolve your complaint with your financial institution or company? Yes No
If Yes, when?	How? Phone Mail In Person Other
Contact Name:		Title:
Has your financial institution responded to you? Yes No
If Yes, when?	How? Phone Mail In Person Other

^{Complaint Information}

^{Describe events in the order they occurred, including any names, phone numbers, and a full description of the problem with the amount(s) and date(s) of any transaction(s). Be as brief and complete as possible to make the explanation clear. Do not include personal or confidential information such as your social security, credit card, or account numbers.}

^{Please be advised that the issues described in this complaint will be shared with the financial institution or company in question.}

^{Privacy Act Statement}

^{The solicitation and collection of this information is authorized by 12 U.S.C. §§ 1, 481, 1464 and 1820; and 15 U.S.C. § 41, et seq.. The information is solicited to provide the Office of the Comptroller of the Currency (OCC) with data that is necessary and useful in reviewing requests received from individuals for assistance in their interactions with national banks or federal savings associations (thrifts). The provision of requested information is voluntary. However, without such information, the ability to complete a review or to provide requested assistance may be hindered. It is intended that the information obtained through this solicitation will be used within the OCC and provided to the national bank or federal savings association (thrift) that is the subject of the complaint or inquiry. Additional disclosures of such information may be made to: (1) other third parties when required or authorized by statute or when necessary in order to obtain additional information relating to the complaint or inquiry; (2) other governmental, self-regulatory, or professional organizations having: (a) jurisdiction over the subject matter of the complaint or inquiry; (b) jurisdiction over the entity that is the subject of the complaint or inquiry; or (c) whenever such information is relevant to a known or suspected violation of law or licensing standard for which another organization has jurisdiction; (3) the Department of Justice, a court, an adjudicative body, a party in litigation, or a witness when relevant and necessary to a legal or administrative proceeding; (4) a Congressional office when the information is relevant to an inquiry initiated on behalf of its provider; (5) Other governmental or tribal organizations with which an individual has communicated regarding a complaint or inquiry about an OCC-regulated entity; (6) OCC contractors or agents when access to such information is necessary; (7) other third parties when required or authorized by statute; and (8) appropriate agencies, entities and persons when (a) there has been a suspected or confirmed compromise to the security or confidentiality of the information in the system of records; (b) as a result of the suspected or confirmed compromise there is a risk of harm to economic or property interests, identity theft or fraud, or harm to the security or integrity of the system or other systems that rely on the compromised information; and (c) the disclosure made is reasonably necessary to assist in efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm.}

^{I certify that the information provided on this form is true and correct to the best of my knowledge.}

I Certify I Do Not Certify

^{Date:____________________}

^{Signature:_____________________________________________}

^{If a valid OMB Control Number does not appear on this form, you are not required to complete this form.}

^{CASE ID}

^{~documentend~}

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