New Jersey Department of Banking and Insurance
Consumer Inquiry and Response Center (“CIRC”)
P.O. Box 471 – Trenton, New Jersey 08625-0471
Phone: (609) 292-7272 Fax: (609) 777-0508 or (609) 292-2431
If you previously contacted the Department and were given a CIRC tracking number, please enter it below.
CIRC Tracking #_______________
New Jersey Division of Banking
Complaint or Inquiry Form
PLEASE PRINT OR TYPE:
Name(s):
Home Address:
City/State/Zip Code:
Home Phone: Business Phone:
Cell: Email Address:
Complaint or Inquiry Involving:
Name of Entity:
Address:
City/State/Zip Code:
Phone:
Date of Transaction/Issue:
Loan Number (if applicable):
PLEASE ATTACH A BRIEF TYPED OR CLEARLY WRITTEN SUMMARY OF YOUR COMPLAINT OR INQUIRY.
THIS SUMMARY SHOULD INCLUDE WHAT TYPE OF RESOLUTION YOU WOULD LIKE TO SEE IN THIS MATTER.
(Be sure to enclose copies of any documentation to support your claim)
PLEASE NOTE: As an initial step, you should try to address this matter in writing with the entity involved and
allow a reasonable period of time for a response. To facilitate your complaint, please provide the Department of
Banking and Insurance with written evidence of your efforts to resolve this matter, including copies of replies
you have received. If you already have such evidence; please submit it along with this completed form. Please
mail/fax this signed form to the above address along with copies of any pertinent documents.
By signing this form, I understand that a copy of this form and enclosures may be sent to the party cited within
the request and authorize the release to the N.J. Department of Banking and Insurance of any records pertinent
to this request.
Signature(s): Date:
10/13
