BOARDING FORM: CFPB Government Portal

BOARDING FORM

 CFPB Government Portal

OMB No. 3170-0057
Expiration Date: XX/XX/XXXX

To access complaint information in the Government Portal, complete and submit this
form to [email protected]. The information you provide enables
us to set up your agency’s access to the Government Portal.

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 (Bureau) will be used to create
a user account so that you may access the web-based Government Portal for the Bureau’s Office of Consumer
Response. Access to the secure, web-based Government Portal will enable you to view complaints and
inquiries. The information you provide on this form may be shared:
§ with parties to 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;
§ with contractors, agents, and others authorized by the Bureau to receive this information; and
§ pursuant to the Bureau’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 the Dodd-Frank Wall Street Reform and Consumer Protection
Act, Public Law 111-203, Title X, Sections 1013(b)(3), 1021, 1034, codified at 12 U.S.C. §§ 5493(b)(3),
5511, 5534.

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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 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 3170-0057.
It expires on XX/XX/XXXX. The time required to complete this information collection is estimated to
average approximately 10 minutes per response. The obligation to respond to this collection of information
is voluntary. 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 Consumer Financial Protection Bureau
(Attention: PRA Office), 1700 G Street NW, Washington, DC 20552, or by email to [email protected].

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GOVERNMENT BOARDING FORM

Agency information

1

AGENCY NAME

AGENCY LOCATION

Contact information
The authorized employee will be the main point of contact for the 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?

YES

NO

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Portal Users Information (continued)

4

If ‘NO’ complete
this section for
each authorized
user.
If you run out
of room here,
you can fill
in additional
authorized users
in Section 6.

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.
NAME

DATE

To submit, save this completed form and email to [email protected].
If the information you provided changes, please email [email protected].

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Addendum

6

If you need to
register additional
users, please enter
them here.
If you run out of
room on this page
to fill in additional
authorized users,
please print/
use multiple
copies of this
page as needed.

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

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