Customer Complaint Form (English)

OMB Control No. 1557-0232
Expiration Date: 07/31/2027

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://banks.data.fdic.gov/bankfind-suite/bankfind). If you do not 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.

The estimated burden for this collection of information is 30 minutes, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. You are not required to respond to any collection of information unless it displays a
currently valid OMB approval number. Comments or questions on the burden estimate, or any other aspect of this
collection of information, can be sent to Office of the Comptroller of the Currency, Chief Counsel's Office, Attn:
Comment Processing, 400 7th Street, SW, Washington, DC 20219 and/or Office of Management and Budget, Desk
Officer for the Office of the Comptroller of the Currency, New Executive Office Building, Room 10202, Washington, DC
20503.
Page 1 of 5

YOUR INFORMATION
The account owner / holder should complete this section.
* - Indicates Required Fields
Name *
Business
Name
Address *

Street Address
City, State, Zip
Country

Phone *
Email

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 submit a copy of any documentation of authorized representation with your
complaint.
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

Representative Name *
Representative Address *

Street Address
City, State, Zip

Representative Phone *
Representative Email

Page 2 of 5

Court Appointed Executor
or Administrator

Other

FINANCIAL INSTITUTION OR COMPANY INFORMATION
THAT IS SUBJECT OF THE COMPLAINT
Helpful Hint: If you do not 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 *

Street Address
City, State, Zip

Phone
Type of Account(s) *
Check all that apply.

Credit Card
Asset Management (Trust Accounts)
Non-Deposit Account
Prepaid Card (including gift cards, reward
cards, or promotional cards)

Deposit Account (Checking, Savings)
Insurance
Consumer Leasing
Loan Product (Consumer, Mortgage,
Home Equity)
Other

Have you tried to resolve your complaint with your financial institution?
No

Yes
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

Contact Name
Title

Page 3 of 5

In Person

Other

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 number, complete 16 digit credit
card number(s), or full bank account number(s).
For complaints related to prepaid cards including gift, reward, and promotional cards,
please include the first 6 digits of the card number and the name of the issuing bank
listed on the back of the card.

Please enter complaint information here.

Please be advised that the issues described in this complaint will be shared with the financial
institution or company in question.
Page 4 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
orlicensing standard for which another organization has jurisdiction;
(2) 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;
(3) a Congressional office when the information is relevant to an inquiry initiated on behalf of its
provider;
(4) other governmental or tribal organizations with which an individual has communicated
regarding a complaint or inquiry about an OCC-regulated entity;
(5) OCC contractors or agents when access to such information is necessary; and
(6) 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/newsissuances/federalregister/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. If
you are deaf, hard of hearing, or have a speech disability, please dial 7-1-1 to access
telecommunications relay services.

Page 5 of 5