Fillable Complaint 2019 (Comptroller of the Currency)

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Complaint 2019 (Comptroller of the Currency)

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The Complaint 2019 (Comptroller of the Currency) form is 5 pages long and contains:

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  • 28 check-boxes
  • 30 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: 06/30/2021
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
1301 McKinney Street, Suite 3450
Houston, TX 77010-9050
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.
Helpful Hints:
Check to make sure your financial institution is a national bank or federal savings
association (thrift). If you do not know the name of your financial institution, check your
account statement. The financial institution's name will be indicated on the statement.
Have you tried to resolve your complaint with your financial institution? 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).
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.
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 *
Street 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
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.
Attorney Representative Not Applicable (skip section)
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 check the following to indicate the type of relationship:
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 *
Street Address *
Phone
Type of Account(s) *
Check all that apply.
Deposit Account (Checking, Savings) Credit Card
Loan Product (Consumer, Mortgage, Home Equity) Asset Management (Trust Accounts)
Consumer Leasing Non-Deposit Account (Investments)
Insurance 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 solicitation and collection of this information is authorized by 12 U.S.C. 1. The information is
solicited to provide the Office of the Comptroller of the Currency (OCC) with data that is
necessary and useful in reviewing requests received from individuals for assistance in their
interactions with national banks or federal savings associations (thrifts). The provision of
requested information is voluntary.
However, without such information, the ability to complete a review or to provide requested
assistance may be hindered.
It is intended that the information obtained through this solicitation 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. Additional disclosures of such information may be made to: (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 having:
(a) jurisdiction over the subject matter of the complaint or inquiry; (b) 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.
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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Complaint 2019 (Comptroller of the Currency)

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Completed 20 July 2020

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