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Federal Deposit
Insurance Corporation

Each depositor insured to at least $250,000 per insured bank

Customer Assistance Form

Formulario de Asistencia para el Consumidor
(En Español)
   FDIC 3064-0134  Expiration Date: 09/30/2018

Privacy Act Statement

The collection of this information is authorized by Section 9 of the Federal Deposit Insurance Act (12 U.S.C. §1819) and Section 202(f) of Title II of the Federal Trade Improvement Act (15 U.S.C. §57a(f)). The FDIC will use this information to respond to your questions and requests for assistance involving activities or practices of FDIC-insured depository institutions. Submitting this information to the FDIC is voluntary. Failure to submit all of the information requested and to complete the form entirely could delay or prevent the response to your request. The information provided by individuals is protected by the Privacy Act, 5 USC §552a. The information may be furnished to the institution which is the subject of the complaint or inquiry; to the Federal or State supervisory authority that has direct supervision over the financial institution; to appropriate Federal, state, local or foreign law enforcement authorities; to a court, administrative tribunal, or a party in litigation; to contractors, agents and other third parties as authorized by law, and in accordance with any of the other routine uses described in the FDIC Consumer Complaint and Inquiry Records (FDIC-30-64-0005) System of Records. A complete copy of this System of Records is available at www.fdic.gov/about/privacy. If you have questions or concerns about the collection or use of the information, you may contact the FDIC’s Chief Privacy Officer at Privacy@fdic.gov.

Last Updated 09/23/2015

Paperwork Reduction Act Statement

Calculamos que el tiempo aproximado para responder a esta recopilación de información es de .25 horas por formulario, incluyendo el tiempo necesario para revisar y leer las instrucciones, buscar las fuentes de datos existentes, reunir y mantener los datos necesarios y completar y revisar la información recopilada. Si usted tiene comentarios sobre nuestro cálculo aproximado de tiempo o cualquier otro aspecto de esta recopilación de información, incluyendo sugerencias para reducir nuestro cálculo de tiempo, escribanos a, Paperwork Reduction Act Clearance Officer, Legal Division, Federal Deposit Insurance Corporation, 550 17th Street, N.W., Washington, D.C. 20429 y al Office of Management and Budget, Paperwork Reduction Project (3064-0134), Washington, D.C. 20503. Una agencia gubernamental no puede realizar ni patrocinar la recopilación de información y una persona no está obligada a responder a esta recopilación de información, salvo que la agencia presente un Numero de Control válido del Office of Management and Budget (o OMB por sus siglas en Ingles) y con fecha de caducidad. El Numero de Control OMB de esta recopilación de información es el 3064-0134 y la fecha de caducidad es el 30 de septiembre del 2018.

Last Updated 09/23/2015

Please complete this form if you have an inquiry or a complaint regarding your financial institution. Once the form has been submitted you will receive the Customer Assistance Confirmation page indicating that your request has been received.

Please note:
  • We cannot act as a court of law or as a lawyer on your behalf.
  • We cannot give you legal or financial advice.
  • We cannot become actively involved in complaints that are in litigation or have been litigated.
* Required Fields
Indicate whether you are a:
Requester Information:
 
Salutation
Title
Middle Name
Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
Home Phone
Business Phone Mobile Phone
*Mailing City *Mailing State/Province  
*Mailing Zip/Postal Code Zip Ext  
*Mailing Country
  Best Way to Contact
  Best Time to Contact
 
Is this request submitted on behalf of you and another individual?  Yes   No
Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
Home Phone
Business Phone Mobile Phone
    Same address as above?    No   Yes
*Mailing City *Mailing State/Province  
*Mailing Zip/Postal Code Zip Ext  
*Mailing Country
 
 
Additional Contact Information:
 
Do you want us to communicate with another individual on your behalf, such as a family member, attorney, or other person representing you about this complaint?
If you list someone you authorize us to communicate with the listed individual and provide information to that individual as well.
 
Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
Home Phone
Business Phone Mobile Phone
*Mailing City *Mailing State/Province  
*Mailing Zip/Postal Code Zip Ext  
*Mailing Country
 
Does your request involve a specific financial institution?
Financial Institution Lookup (New Window)
Mailing City Mailing State/Province  
Mailing Zip/Postal Code Zip Ext  
Mailing Country
Institution Phone Number Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
FI: Type of accounts
Have you tried to resolve your complaint with your financial institution or company?
MM/DD/YYYY   *Resolve: How    Phone   Mail   In Person   Other 
Resolve: Contact Name Resolve:Title
Have you filed a complaint or contacted another government agency?
*Gov Agency: Agency Name
 
 
Complaint Information:
 
Describe events in the order in which 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). Do not include personal or confidential information such as your social security, credit card, or bank account numbers. If you need to provide COPIES of any supporting documentation such as contracts, monthly statements, receipts or any correspondence with the bank (do not send original documents), you may mail or fax this information to:
FDIC Consumer Response Center
1100 Walnut Street, Box #11
Kansas City, MO 64106
1-877-ASK-FDIC (1-877-275-3342)
(Monday - Friday 8:00 am to 8:00 pm EST)
703-812-1020 (Fax number)
*Please describe below the nature of your complaint or inquiry.
Please be advised that the issues described in this complaint will be shared with the financial institution or company in question for their response.
 
*Desired Resolution
What action by the financial institution or company would resolve this matter to your satisfaction?
 
 
*Checking this box authorizes the FDIC to respond and investigate (if applicable) your concerns.
 
 

FDIC 6422/04 (9-12)
Last Updated 12/11/2017

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