Please note: We will review your complaint as soon as possible, however, please allow 30 days for a response. We cannot act as a court of law or as a lawyer on your behalf We cannot give you legal advice We cannot become involved in complaints that are in litigation or have been litigated * Required fields Personal information Personal Information Salutation Salutation - None -MissMsMrMrsDrOther… Enter other… First name MI Last name Address Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Primary phone number e.g., (573-555-1212) Secondary phone number e.g., (573-555-1212) Email Additional contact information If you want us to communicate with someone else, such as a family member, attorney or other person representing you regarding this complaint, please provide your representative's information below. We may share any information regarding this matter with the representative you list. Name of representative Relationship Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Phone e.g., (573-555-1212) Financial institution or company subject to the complaint Name of institution Address Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Phone e.g., (573-555-1212) Type of accounts Deposit accounts - None -Test AccountCheckingSavingCDTrust Loans - None -Credit CardPersonalReal EstateCommercial Other Have you tried to resolve your complaint with the financial institution or company? - None -YesNo If yes, when? Describe Contact name Title Have you filed a complaint or contacted another government agency? - None -YesNo If yes, agency name? Agency contact 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 dates(s) of any transaction(s). Be brief, but provide enough information to explain your situation. You may be requested to supply copies of documents related to your complaint such as contracts, monthly statements, receipts, and correspondence with the financial institution. Details of my complaint Please be advised that the issues described in this complaint may be shared with the financial institution or company for a response. It may also be shared with other government agencies that have jurisdiction in the matter. Desired resolution What action by the financial institution or company would resolve this matter to your satisfaction? I certify that the information provided is true and correct to the best of my knowledge. Submitted by Attachment One file only.256 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, psd, txt, rtf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml. Please DO NOT provide any personal or sensitive information when filling out this form, such as a social security number, credit card, health information, account number, etc.
