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
Global notes
Net new fields are highlighted in green
ABOUT THE ISSUE
This section is designed to capture information needed to investigate and respond to complaints.
*All Products, Services, Sub-Product, Sub-Services, Issues, and Sub-Issues are listed in Attachment 2.
What is this complaint about?* Choose the product or service that best matches your complaint. [RADIO BUTTON]
Product or Service (e.g., student loan)
Sub-Product or Sub-Service (e.g., private student loan)
Prompts for Item 2 are driven by response to Item 1.
What type of problem are you having?* Most of the (driven by sub-product or sub-service selected in Item 1) complaints we get are about one of the following topics. Select the one that best describes your complaint. You will have the chance to explain your complaint in detail in the next step.
[RADIO BUTTON]
Issue (e.g., getting a loan)
Sub-Issue (optional) (e.g., denied loan)
The web form uses the response to Item 1 to suggest possible issues and sub-issues.
Have you already tried to fix this problem with the company?* [RADIO BUTTON]
Yes
No
Did you request information from the company?* [RADIO BUTTON]
Only appears if the user selects “Yes” in Item 3.
Yes
No
What information did you request? (optional) [TEXT]
Only appears if the user selects “Yes” in Item 4.
Text box provides examples: (statements, notices, loan documents)
Did the company provide this information?* [RADIO BUTTON]
Only appears if the user selects “Yes” in Item 4.
Yes
No
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.
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]
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]
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.
What company is this complaint about?* Start typing the ‘Company name’ below. Select a company from the list or provide the company’s contact information. [AUTO COMPLETE OR TEXT]
If the user-entered company name is not in the system, the user is prompted to provide additional 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 [PICKLIST]
ZIP code
Website
Phone number
Other identifying characteristics
Include any details that could help us identify the company, such as the location of store branches or descriptions of branding, logos, or advertising.
Providing this information helps the company find your account in their system. (optional) [NUMBER or TEXT]
Fields in Item 12 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
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.
Is this complaint for you or someone else?* 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]
Myself
I am submitting this complaint for myself
Someone else
The consumer has authorized me to submit this complaint for them
Your contact information
The above text changes to state “Your information” if the user selects “Someone else” in Item 13. The submitter is then prompted for “Your information” in Item 15 and “The consumer’s contact information” in Item 16.
First Name* [TEXT], Middle Name [TEXT], Last Name* [TEXT], Suffix [PICKLIST ]
Address line 1* [TEXT], Address line 2 [TEXT], City* [TEXT], State* [PICKLIST], ZIP or postal code* [TEXT], Country* [PICKLIST], Phone Number* [NUMBER], Email* [Pre-populated from account], Preferred Language [PICKLIST; If “Other language” is selected a text field appears to “Please specify which language*]
First name, last name, email address, and phone number fields are collected upon account registration to ensure an appropriate amount of identifying information is captured on the web form to validate consumers when they call the contact center.
Your information
Only appears if the user selects “Someone else” in Item 13. The submitter must also provide “The consumer’s contact information” in Item 16.
First Name* [TEXT], Last Name* [TEXT]
Relationship to the consumer you are submitting a complaint for* [PICKLIST]
The consumer’s contact information
Only appears if the user selects “Someone else” in Item 13.
First Name* [TEXT], Middle Name [TEXT], Last Name* [TEXT], Suffix [PICKLIST ]
Address line 1* [TEXT], Address line 2 [TEXT], City* [TEXT], State* [PICKLIST], ZIP or postal code* [TEXT], Country* [PICKLIST], Phone Number* [NUMBER], Email address* [TEXT], Re-enter email address* [TEXT], Preferred Language [PICKLIST; If “Other language” is selected a text field appears to “Please specify which language*]
First name, last name, email address, and phone number fields are collected upon account registration to ensure an appropriate amount of identifying information is captured on the web form to validate consumers when they call the contact center. The consumer’s first name, last name, phone number, and email address are also necessary for the same purpose when someone else files their complaint.
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]
Age [NUMBER]
Sex [RADIO BUTTON]
If Write-in is selected [TEXT]
Hispanic, Latino, or Spanish Origin [RADIO BUTTON]
Race [CHECKBOX]
If Other race is selected [TEXT]
Household size including total number of adults and children [PICKLIST]
Combined annual household income [PICKLIST]
Servicemember status [CHECKBOX]
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:
Current status* [PICKLIST]
Branch of service* [PICKLIST]
Rank [PICKLIST]
Military base/location [PICKLIST]
Data Driven Questions
This section captures questions that are only asked in response to certain selections in Item(s) 1 and/or 2.
If you are completing this form about a mortgage issue, please answer these questions.
On the web form, Item 17 and its subparts only appear when the response to Item 1 is Mortgage.
Please specify* [TEXT]
This field only appears when the user selects Mortgage as their product and Other as their sub-product.
What was the purpose of this mortgage? [RADIO BUTTON]
This field only appears when the user selects Conventional, FHA, VA, USDA, Manufactured home, or Other as their sub-product and either Applying for a mortgage or refinancing an existing mortgage or Closing on a mortgage as their issue.
Have you missed any mortgage payments or are you in default on your mortgage? [RADIO BUTTON]
If Yes, continue to Item d
If No, proceed to next page
Is there a date that is scheduled for the foreclosure sale of your home?
[RADIO BUTTON]
If Yes, continue to item e
If No, proceed to the next page
When is the scheduled foreclosure sale? You can find this date on the "Notice of Sale" or "Order Setting Sale" documents. [DATE]
If you are completing this form about a payday loan, title loan, personal loan, or advance loan issue, please answer these questions.
On the web form, Item 18 and its subparts only appear when the response to Item 1 is Payday loan, title loan, or personal loan.
Where did you get the loan? [RADIO BUTTON]
The user may indicate “Online” or “In-person/at a store (even if you applied online)”
If “Online,” the user is asked for the company’s website [TEXT]
If “In-person/at a store,” user is asked for the US state where the store is located [TEXT]
Did you take out this loan to repay a previous loan? [RADIO BUTTON]
Was the product provided by or through your employer? [RADIO BUTTON]
This field only appears when the user selects Earned wage access as their sub-product.
If you are completing this form about a credit reporting issue, please answer these questions:
In the web form, Item 19 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 complain about another company? [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]
If you are completing this form about a prepaid card issue, please answer these questions:
In the web form, Item 20 and its subparts only appear when the response to item 1 is General-purpose prepaid card or Student prepaid card
(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]
(If Student prepaid card is selected) Is your student loan or financial aid refund automatically loaded onto the card?* [RADIO BUTTON]
If you are completing this form about a vehicle loan or lease issue, please answer these questions:
In the web form, Item 21 and its subparts only appear when the response to Item 1 is vehicle loan or lease
(If vehicle loan is selected) Was the loan for a new or used vehicle?* [RADIO BUTTON]
(If vehicle lease is selected) Was the lease for a new or used vehicle?* [RADIO BUTTON]
If you are completing this form about a student loan issue, please answer these questions:
In the web form, Item 22 and its subparts only appear when the response to Item 1 is related to a Student loan.
If you are completing this form about a money transfer issue, please answer these questions:
In the web form, Item 23 and its subparts only appear when the response to Item 2 is Mobile or digital wallet
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]
If you are completing this form about a checking or savings account issue, please answer these questions:
In the web form, Item 24 only appears when the response to Item 2 is Other banking product or service
What is the “Other” banking service or product? [TEXT]
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 (CFPB) to respond to your complaint or inquiry about companies and services we regulate. Information about your complaint or inquiry (including your personally identifiable information (PII) may be shared:
with the entity that is the subject of your complaint;
with third parties as necessary to get information relevant to responding to your 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; and
with other federal or state agencies or regulatory authorities for enforcement and statutory purposes; and
We may also share your complaint or inquiry (but not your PII) with the public through the public Consumer Complaint Database.
Although the Bureau does not otherwise anticipate further disclosing the information provided, it may also be disclosed as indicated in the Routine Uses described in the System of Records Notice CFPB.005 – Consumer Response System.
The collection of information is authorized by Pub. L. No. 111-203, Title X, Sections 1011, 1012, 1013(b)(3), 1021, 1034, codified at 12 U.S.C. 5491, 5492, 5493(b)(3), 5511, 5534.
Submitting a complaint is voluntary. You are not required to submit a complaint or share any PII, 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 process your complaint.
Paperwork Reduction Act Statement
OMB #3170-0011
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the collection of information displays a valid control number assigned by the Office of Management and Budget (OMB). The OMB control number for this collection is 3170-0011, expires XX/XX/XXXX.
* Answers to these questions are necessary for the CFPB to take action.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Aminpour, Leila (CFPB) |
| File Modified | 0000-00-00 |
| File Created | 2022-10-13 |