Fillable CUSTOMER COMPLAINT FORM (Comptroller of the Currency)

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CUSTOMER COMPLAINT FORM (Comptroller of the Currency)

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The CUSTOMER COMPLAINT FORM (Comptroller of the Currency) form is 5 pages long and contains:

  • 1 signature
  • 28 check-boxes
  • 29 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Comptroller of the Currency

BROWSE COMPTROLLER OF THE CURRENCY (DC) FORMS

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Page 1 of 5
OMB Control No. 1557-0232
Expiration Date: 07/31/2024
CUSTOMER COMPLAINT FORM
Please fill in this form completely. Mail or fax this completed complaint form to:
Office of the Comptroller of the Currency
Customer Assistance Group
P.O. Box 53570
Houston, TX 77052
1-713-336-4301 (Fax)
Once we receive your completed form, you will receive an acknowledgment letter containing
your assigned case number. Please keep your case number for future contact with our
office.
The OCC recommends that you attempt to resolve your complaint with your financial
institution first. Please contact your financial institution to allow them the opportunity to
resolve your issue(s).
Helpful Hints:
• Check to make sure that your financial institution is a national bank or federal
savings association (thrift). Search Financial Institutions (https://www.ffiec.gov/
consumercenter/default.aspx). If you don't know the name of your financial institution,
check your bank or credit card statement. The institution's name will be indicated on the
statement.
• If your complaint involves more than one financial institution, you will need to submit a
separate complaint form for each institution involved. You will receive separate case
numbers for each institution. Do NOT send additional information unless requested.
Please Note:
• 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.
Page 2 of 5
YOUR INFORMATION
The account owner / holder should complete this section.
* - Indicates Required Fields
Name *
Address *
Phone *
E-mail
What is the best way to contact you?
Phone Mail E-mail
What is the best time to contact you?
Morning Afternoon Evening
REPRESENTATIVE CONTACT INFORMATION
If you want us to communicate with your attorney or other legal representative directly, please
provide the information below. Your submission of this portion of the form authorizes our
office to release information to your attorney or other legal representative if requested.
Please indicate the Type of Relationship *
Attorney Legal Representative
Please indicate the Type of Authorization you have granted to your Attorney or
Representative *
If you are not sure of the type of legal authorization granted, please check your legal documents or consult with
your attorney or other legal representative.
Power of Attorney Letters Testamentary
Court Appointed Executor
or Administrator
Other
Representative Name *
Representative Address *
Rep. Phone *
Rep. E-mail
What is the best way to contact your
representative?
Phone Mail E-mail
What is the best time to contact your
representative?
Morning Afternoon Evening
Page 3 of 5
FINANCIAL INSTITUTION OR COMPANY INFORMATION
THAT IS SUBJECT OF THE COMPLAINT
Helpful Hint: If you don't know the name of your financial institution, check your bank or credit
card statement. The institution's name will be indicated on the statement.
Name of Financial
Institution or Company *
Address *
Phone
Type of Account(s) *
Check all that apply.
Deposit Account (Checking, Savings) Credit Card
Insurance Asset Management (Trust Accounts)
Consumer Leasing Non-Deposit Account (Investments)
Loan Product (Consumer, Mortgage,
Home Equity)
Other
Have you tried to resolve your complaint with your financial institution?
Yes
No
If Yes, when?
How?
Phone Mail In Person Other
Has the financial institution responded to your complaint?
Yes No
If Yes, when?
How?
Phone Mail In Person Other
Contact Name
Title
Page 4 of 5
COMPLAINT INFORMATION *
Describe events in the order 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). Be as brief and
complete as possible to make the explanation clear. Do not include personal or confidential
information such as your social security, credit card, or bank accounts numbers.
Please be advised that the issues described in this complaint will be shared with the financial institution
or company in question.
Page 5 of 5
PRIVACY ACT STATEMENT
The information you provide to the Office of the Comptroller of the Currency (OCC) will permit us to
respond to your complaint or inquiry about the national banks or federal savings associations (thrifts) we
supervise.
The collection of this information is authorized by 12 USC 1.
Your submission of information to the OCC is entirely voluntary. You are not required to submit any
information or to submit a complaint. However, if you do not submit the requested information, the OCC
may not be able to process your request or inquiry.
Information about your complaint or inquiry will be used within the OCC and provided to the national
bank or federal savings association (thrift) that is the subject of the complaint or inquiry. Additionally,
this information may be shared with the following, pursuant to published routine uses:
(1) other third parties when required or authorized by statute or when necessary in order to
obtain additional information relating to the complaint or inquiry;
(2) other governmental, self-regulatory, or professional organizations
(a) having jurisdiction over the subject matter of the complaint or inquiry;
(b) having jurisdiction over the entity that is the subject of the complaint or inquiry; or
(c) whenever such information is relevant to a known or suspected violation of law or
licensing standard for which another organization has jurisdiction;
(3) the Department of Justice, a court, an adjudicative body, a party in litigation, or a witness when
relevant and necessary to a legal or administrative proceeding;
(4) a Congressional office when the information is relevant to an inquiry initiated on behalf of its
provider;
(5) other governmental or tribal organizations with which an individual has communicated
regarding a complaint or inquiry about an OCC-regulated entity;
(6) OCC contractors or agents when access to such information is necessary; and
(7) other third parties when required or authorized by statute.
You may find additional information regarding the rights and obligations related to the OCC's collection
of the requested information at 81 FR 2945-01, 2957 (https://www.occ.gov/news-issuances/federal-
register/2016/81fr2946.pdf).
I certify that the information provided on this form is true and correct to the best of
my knowledge. *
I Certify I Do Not Certify
Signature *
Date *
We will mail you a written acknowledgment within five (5) business days of receipt of your completed
complaint form containing your assigned case number. Please utilize your case number for future
contact with our office. If you have any questions regarding this case, please call 1-800-613-6743 (TTY:
800-877-8339 via a relay service).
If a valid OMB Control Number does not appear on this form, you are not required to complete this form.
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CUSTOMER COMPLAINT FORM (Comptroller of the Currency)

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Completed 3 September 2021

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