Customer Assistance Form

Formulario de Asistencia para el Consumidor
(En Español)

			OMB 3064-0134
			Expiration Date: 11/30/2018

Privacy Act Statement

The collection of this information is authorized by Section 9 of the Federal Deposit Insurance Act (12 U.S.C. §1819) and Section 202(f) of Title II of the Federal Trade Improvement Act (15 U.S.C. §57a(f)). The FDIC will use this information to respond to your questions and requests for assistance involving activities or practices of FDIC-insured depository institutions. Submitting this information to the FDIC is voluntary. Failure to submit all of the information requested and to complete the form entirely could delay or prevent the response to your request. The information provided by individuals is protected by the Privacy Act, 5 USC §552a. The information may be furnished to the institution which is the subject of the complaint or inquiry; to the Federal or State supervisory authority that has direct supervision over the financial institution; to appropriate Federal, state, local or foreign law enforcement authorities; to a court, administrative tribunal, or a party in litigation; to contractors, agents and other third parties as authorized by law, and in accordance with any of the other routine uses described in the FDIC Consumer Complaint and Inquiry Records (FDIC-30-64-0005) System of Records. A complete copy of this System of Records is available at www.fdic.gov/about/privacy. If you have questions or concerns about the collection or use of the information, you may contact the FDIC’s Chief Privacy Officer at privacy@fdic.gov.

Privacy Act Statement Updated 09/23/2015

Paperwork Reduction Act Statement

Public reporting burden for this collection of information is estimated to average .25 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and review the collection of information.

Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Paper Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17th Street, N.W., Washington, D.C. 20429, and the Office of Management and Budget, Paperwork Reduction Project (3064-0134), Washington, D.C. 20503.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection unless it displays a currently valid OMB control number.

Paperwork Reduction Act Statement Updated 09/23/2015

*Last Name

*First Name

Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)

Home Phone

Business Phone

Mobile Phone

Same address as above? No Yes

*Mailing Street
Street Address, line 2
*Mailing City		*Mailing State/Province
*Mailing Zip/Postal Code		Zip Ext
*Mailing Country

Additional Contact Information:

Do you want us to communicate with another individual on your behalf, such as a family member, attorney, or other person representing you about this complaint?

Yes

If you list someone you authorize us to communicate with the listed individual and provide information to that individual as well.

*Representative Last Name

*First Name

Relationship

Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)

Home Phone

Business Phone

Mobile Phone

*Mailing Street

Street Address, line 2

*Mailing City

*Mailing State/Province

*Mailing Zip/Postal Code

Zip Ext

*Mailing Country

Does your request involve a specific financial institution?

Yes

*Financial Institution

Mailing Street

Street Address, line 2

Mailing City

Mailing State/Province

Mailing Zip/Postal Code

Zip Ext

Mailing Country

Institution Phone Number

Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)

FI: Type of accounts

Have you tried to resolve your complaint with your financial institution or company?

Yes

*When?

MM/DD/YYYY

*Resolve: How Phone Mail In Person Other

Resolve: Contact Name

Resolve:Title

Have you filed a complaint or contacted another government agency?

Yes

*Gov Agency: Agency Name



Complaint Information:

Describe events in the order in which 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). Do not include personal or confidential information such as your social security, credit card, or bank account numbers. If you need to provide COPIES of any supporting documentation such as contracts, monthly statements, receipts or any correspondence with the bank (do not send original documents), you may mail or fax this information to:
FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106 1-877-ASK-FDIC (1-877-275-3342) (Monday - Friday 8:00 am to 8:00 pm EST) 703-812-1020 (Fax number)

*Please describe below the nature of your complaint or inquiry. Please do not attach documents or cut and paste into this space. You will be contacted if more information is needed.

Please be advised that the issues described in this complaint will be shared with the financial institution or company in question for their response.

*Desired Resolution What action by the financial institution or company would resolve this matter to your satisfaction?
Please do not attach documents or cut and paste into this space. You will be contacted if more information is needed.



*Checking this box authorizes the FDIC to respond and investigate (if applicable) your concerns.

FDIC 6422/04 (9-12)

For questions regarding this form, email forms@fdic.gov.

Page Updated 12/11/2018