Form FR 1379c FR 1379c Consumer Online Complaint Form

FR 1379c
OMB Number 7100–0135
Expires February 28, 2023
Page 1 of 2

Board of Governors of the Federal Reserve System

Consumer Complaint Form
This form is authorized by law (15 U.S.C. §57(a)(f)(1)) and is voluntary.
Your Information
Prefix:

Mr.

Mrs.

Ms.

Dr.

*First Name:

*Last Name:

*Address:
City

Email:
*Phone:

State / Province

Alternate Phone:

Zip Code

*Contact Preference:

Mail

Country

Email

Representative Contact
Do you want us to communicate with a third party, such as an attorney or other legal representative, regarding this complaint?
Yes

No

If you checked No, skip to Institution Information.

By selecting Yes, you legally authorize the Federal Reserve System to release information to and communicate directly with the party
named below and for that party to act on your behalf in the processing of this complaint.
Prefix:

Mr.

Mrs.

Ms.

Dr.

*First Name:

*Last Name:

*Address:
City

Email:

State / Province

*Phone:

Zip Code

Country

Alternate Phone:

Institution Information
Please provide as much information as possible about the bank or financial institution.
*Institution Name:
Account / Product Type:

Routing Number:

*Address:
City

State / Province

Zip Code

Country

If you do not have the exact address of the bank or financial institution, provide a location, such as the nearest cross streets or
major intersection.

Email:

*Phone:
Please print clearly.
Mail or fax this completed form to:
Federal Reserve Consumer Help
PO Box 1200, Minneapolis, MN 55480
Fax: 877-888-2520
Questions? Call us at 888-851-1920

*Required Fields
Pubic reporting burden for this information collection is estimated to average ten minutes per response. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden, to Secretary, Board of Governors of the Federal Reserve System, 20th and C Streets, NW, Washington, DC 20551; and to
the Office of Management and Budget, Paperwork Reduction Project (7100‐0181), Washington, DC 20503.

01/2020

FR 1379c
Page 2 of 2

Interagency Appraisal Complaint Form—Continued
Complaint
*Provide a brief description of the complaint including dates and the names of those you dealt with.
Do NOT include any personal information such as account numbers or Social Security numbers.

How can your complaint be satisfactorily addressed?

*Required Fields

Privacy Notice
The information you are providing is being collected pursuant to
the individual authorities of the federal financial institution regulators (12 U.S.C. §§ 1481, 1464, 1756, 1766, 1820, and 1844 in
connection with a complaint made pursuant to 12 U.S.C. § 3351(i).
The information provided will be used to ensure the appropriate
regulator receives your complaint and by the regulator to review
and respond to your complaint. In order to review and respond to
your complaint, the appropriate regulator may disclose your information consistent with the routine uses listed in the regulators'
respective Privacy Act Statement:

Signature

OCC (www.helpwithmybank.gov/policies/policies-privacy.html),
FDIC (www.fdic.gov/consumers/questions/Priv_statement.html),
FRB (www.federalreserve.gov/privacy.htm), and,
NCUA (www.ncua.gov/privacy/website-privacy-policy).
Do not include any information in your complaint you consider confidential or do not want disclosed during the complaint review process. While completing this form is voluntary, failure to provide all
of the information may delay or prevent the appropriate regulator
from reviewing your complaint.

Date (MM/DD/YYYY)

01/2020