Boarding Form (CFPB Government Portal)

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BOARDING FORM

CFPB Government Portal

OMB No. 3170-0057

Expiration Date: 08/31/2025

To request access to complaint information available in the CFPB Government Portal, complete and submit this form to [email protected].

The CFPB may, in its discretion, approve or deny any access request to the Government Portal.

Notice of Collection under the Privacy Act of 1974, 5 U.S.C. 552a(e)(3) (Privacy Act Statement)

The information that you provide to the Consumer Financial Protection Bureau (CFPB) will be used to create a user account and provide access to the web-based Government Portal. Account access to the web-based Government Portal will enable you to view the complaints or inquiries. The information you provide in the portal and boarding form (including personally identifiable information (PII)) may be shared:

• with parties to a complaint;

• with a court, magistrate, or administrative tribunal in the course of a proceeding;

• for enforcement, statutory, and regulatory purposes;

• with another federal or state agency or regulatory authority;

• with a member of Congress; to the Department of Justice, a court, an adjudicative body or administrative tribunal, or a party in litigation; and

• with the public, members of the media, federal, state, and local government officials, or other recipients of public relations materials issued by the CFPB about the activities of the CFPB.

Although the CFPB 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.

Creating an account is voluntary. You are not required to provide any PII; however, if you do not include the requested information you may not be granted access to the Government Portal.

Agency information

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1. AGENCY NAME

AGENCY LOCATION

Click the box that best applies to your agency.

 Federal agency

 State agency

(State means any state, territory, or possession of the United States, the District of Columbia, the Commonwealth of Puerto Rico, the Commonwealth of the Northern Mariana Islands, Guam, American Samoa, or The U.S. Virgin Islands)

 Federally recognized American Indian or Alaska Native tribal entity

 County or city government*

*County or city governments with delegated authority from a state agency should provide confirmation of delegated authority in question 2 below or as an attachment to this access request.

Authority to review, possess, and examine consumer financial complaints

2

As outlined in 12 CFR 1070.43(b)(2), provide below or attach with this request, a citation to your agency’s legal authority to review, possess, and examine consumer complaints about financial products and services.

Please be specific when citing the relevant legal authority. The cited legal authority should be your agency’s authority to supervise, enforce, regulate, research, and/or monitor markets related to consumer financial products and services.

Does your agency originate, service, and/or perform debt collection activities for any consumer financial product or service?

• Yes (please additional information below)

• No

If yes, please provide the statutory authority to perform such activities, if any. Please write N/A if there is no supporting statutory authority.

To your knowledge, is your agency subject to or has your agency ever been subject to a supervisory or enforcement action by a governmental entity?

• Yes

• No

Contact information

3

If the CFPB approves your agency’s request for access, your agency must authorize employee(s) to be your point(s) of contact for the Government Portal. These people must recertify your agency’s access annually and will be the only people authorized to add or remove users. Provide business contact information for at least one employee authorized to perform such duties. You may add a second optional employee authorized to perform such duties.

NAME OF AUTHORIZED EMPLOYEE (REQUIRED) TITLE

EMAIL PHONE NUMBER

STREET

CITY STATE ZIP CODE

NAME OF SECOND AUTHORIZED EMPLOYEE (OPTIONAL) TITLE

EMAIL PHONE NUMBER

STREET

CITY STATE ZIP CODE

Portal Users Information

4

If the CFPB approves your agency’s request for access, we will need the following business contact information to set up the user profiles for each individual authorized by your agency to have access.

Is the authorized employee (from Section 2) the only authorized

Government Portal user in your office? YES NO

If ‘NO’ complete this section for each authorized user.

NAME OF AUTHORIZED USER

EMAIL

TITLE

PHONE NUMBER

If you run out

of room here,

you can fill

in additional

authorized users

in Section 6.

NAME OF AUTHORIZED USER

EMAIL

TITLE

PHONE NUMBER

Submit

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• 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

EMAIL

NAME OF AUTHORIZED USER

EMAIL

TITLE

PHONE NUMBER

TITLE

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

Consumer Financial Protection Bureau

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