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LETTER OF AUTHORIZATION

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 DFSCaseNumber

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I. ConsumerAuthorization–RequiredforallMortgageBanking&StudentLoancomplaints

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ConsumerName:

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FinancialInstitution:

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Address:  Address:

City,State,Zip:  City,State,Zip:

TelephoneNumber:  LoanNumber:

EmailAddress:  AdditionalInfo:

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I/WeauthorizetherespondenttofurnishtotheDepartmentofFinancialServiceswithanyinformationrelatedto

thismatter.IamenclosingcopiesofcorrespondenceorotherpaperswhichIfeelwould helpthisinvestigation.I

understandthatacopyofthisformandanyoralloftheenclosedinformationmaybesenttotherespondent.

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ConsumerSignature: Date:

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Co‐BorrowersSignature:

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Date:

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II. RepresentativeAuthorization–RequiredonlyifcomplaintisfiledbyaRepresentative

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RepresentativeName:

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Address: 

City,State,Zip: 

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Thisletterconfirmsmy/ourdesignationoftheabovecaptionedindividualorfirmasmy/ourrepresentative(“The

Representative”)concerningmy/ourrequestforassistance(“RFA”)totheNew YorkStateDepartmentofFinancial

Services(“TheDepartment”),including(checkallthatapply):

____TheRepresentativeisherebydeemedmy/ouragentandgrantedauthorityto

actonmy/ourbehalf;

____TheRepresentativeisherebygrantedtherightofaccesstoinformationandrecords;Allcommunicationsareto

bewith,anddirectedtotheattentionof,my/ourRepresentative.However,thisdoesnotprecludemy/our

intervention.

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I/weunderstandthatwhenreleasinginformationand/orrecordstoanauthorizedthirdparty,theDepartmenthas

noauthoritytocontrolitsfutureuseordissemination.Therefore,I/wereleasetheDepartmentandanyofficers,

agents,oremployees,thereof,fromanyandallliabilitythatmayariseoutoftheRe presentative’s possessionand/or

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useofsuchinformationand/orrecords.

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ThiswrittenauthorizationiseffectivethedatesignedandwillremainineffectforaONEYEARperiodfromthedate

signedbelow:

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ConsumerSignature: Date: 

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Co‐BorrowersSignature: Date: 

Stateof___________ Countyof_____ ______  SubscribedandSworntobeforeme

this_____dayof______________20__by     (nameofsigner(s))

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NotarySignature:Seal/Stamp:

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NYCIS Letter Of Authorization MBKG SPU NYCIS Letter of Authorization

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