Form fr 1379C fr 1379C Federal Reserve Consumer Help - Consumer Online Complain

DRAFT 10/20/2010

Consumer Complaint Form
Step 1 - Contact Information | Step 2 - Institution Information | Step 3 - Complaint
FR 1379c
OMB No. 7100-0135
Approval expires May 31, 2011
March 31, 2014

* Required Fields

Prefix
* First Name
* Last Name
* Address
* City
* State
* Zip Code
* Country

United States

Email Address
* Phone Number
Alternate Phone
* Contact Preference

Select your preference

DRAFT 10/20/2010

Consumer Complaint Form
Step 1 - Contact Information | Step 2 - Institution Information | Step 3 – Complaint
FR 1379c
OMB No. 7100-0135
Approval expires March 31, 2014

* Required Fields
Representative Contact

Is a third party, such as an attorney or other legal representative, submitting this complaint
on your behalf?
Yes

No

{The section below appears only if ‘yes’ is selected above}

By selecting ‘Yes’, you legally authorize the Federal Reserve System to release
information to and communicate directly with the party named below and for that
party to act on your behalf in the processing of this complaint.
Prefix
* First Name
* Last Name
* Address
* City
* State
* Zip Code
* Country
Email Address
* Phone Number
Alternate Phone

United States

DRAFT 10/20/2010

Consumer Complaint Form
Step 1 - Your Information | Step 2 - Institution Information | Step 3 - Complaint
FR 1379c
OMB No. 7100-0135
Approval expires May
31, 2011

* Required Fields

Provide as much information as possible about the bank or financial institution.
* Institution Name
Account/Product Type
Routing Number
Address/Location
* City
* State
Zip Code
* Country

United States

Email Address
Phone Number

DRAFT 10/20/2010

Consumer Complaint Form
Step 1 - Your Information |

Step 2 - Institution Information |

Step 3 - Complaint
FR 1379c
OMB No. 7100-0135
Approval expires May 31, 2011

* Required Fields

* Complaint - To help us get the investigation process started, provide a brief description of
the complaint including dates and the names of those you dealt with.
Do NOT include any personal information such as account numbers or Social Security
numbers.
In order to protect the integrity of your complaint and for security purposes, limited special
characters are allowed in your description. They include: ? - $ ! . , : ; ( ) % & ' / "

characters remaining for your description.
How can your complaint be satisfactorily addressed?

characters remaining for your description.
How did you learn about Federal Reserve Consumer Help? Check all that apply.
Federal Reserve website/other website/search engine

specify:

Bank/financial services company/consumer brochure

specify:

Referral from another federal/state agency

specify:

Friend/relative/newspaper/magazine article/other

specify:

DRAFT 10/20/2010

Review our Privacy Act Statement.
PAPERWORK REDUCTION ACT NOTICE
This form is authorized by law (15 U.S.C. §57(a)(f)(1)) and is voluntary.
Public reporting burden for this information collection is estimated to average ten 10
minutes per response. Send comments regarding this burden estimate or any other
aspect of this information collection, including suggestions for reducing this burden,
to Secretary, Board of Governors of the Federal Reserve System, 20th and C
Streets, N.W., Washington, DC 20551; and to the Office of Management and Budget,
Paperwork Reduction Project (7100-0181), Washington, DC 20503.