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CONSUMER COMPLAINT FORM
*RequiredFields
FR 1379c - OMB No. 7100-0135
Approval expires February 28, 2026
Please print clearly below.
Mail or fax this completed form to:
Federal Reserve Consumer Help
PO Box 1200, Minneapolis, MN 55480
Fax: 877-888-2520
Questions? Call us at 888-851-1920
YOUR INFORMATION
Prefix: Mr. Mrs. Ms. Dr. *FirstName: *LastName:
*Address:
City State ZipCode Country
E‐mail:
*Phone: AlternatePhone: *ContactPreference: Mail E‐Mail
REPRESENTATIVE CONTACT
Doyouwantustocommunicatewithathirdparty,suchasanattorneyorotherlegalrepresentative,regardingthiscomplaint?
Yes No Ifyouchecked‘No’,skiptoInstitutionInformation.
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: Mr. Mrs.
Ms.
Dr.
*FirstName: *LastName:
*Address:
City State ZipCode Country
E‐mail:
*Phone: AlternatePhone:
INSTITUTION INFORMATION
Pleaseprovideasmuchinformationaspossibleaboutthebankorfinancialinstitution.
*InstitutionName:
Account/ProductType: Routing Number:
*Address:
City State ZipCode Country
Ifyoudonothavetheexactaddressofthebankorfinancialinstitution,providealocation,suchasthenearestcrossstreets
ormajorintersection.
E‐mail: Phone:
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FR 1379c
COMPLAINT
*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.
Howcanyourcomplaintbesatisfactorilyaddressed?
PrivacyActStatement
TheinformationthatyouprovidewillpermittheFederalReservetorespondtoconsumercomplaintsandinquiriesregardingpracticesbybanksandother
financialinstitutionssupervisedbytheBoard.Theinformationyoup rovi dewillbestoredinthesystemofrecordsen titledBGFRS‐18,"FRB‐Consumer
ComplaintInformation"andmaybedisclosedforthefollowingpurposes:
•
toaBoard‐regulatedentitythatisthesubjectofacomplaintorinquiry;
•
tothirdpartiestotheextentnecessarytoobtaininformationthatisrelevanttotheresolutionofacomplaintorinquiry;
•
forenforcement,statutory,andregulatorypurposes;
•
toanotheragencyorFederalReserveBank;
•
toamemberofCongress;
•
totheDepartmentofJustice,acourt,anadjudicativebodyoradministrativetribunal,orapartyinlitigation;
•
tocontractors,agents,andothers;
•
tofacilitatearesponsetoabreachoftheBoard;and
•
toassistanotherfederalagencyorfederalentityinrespondingtoabreach.
Thiscollectionofinformationisauthorizedby12U.S.C.§§248and1844,15U.S.C.§57a(f),andotherconsumerprotectionlaws.
Youarenotrequiredtofileacomplaintorinquiryandyoumaywithdrawyourcomplaintorinquiryatanytime.
However,ifyoudoso,theFederalReservemaynotbeabletoinvestigateyourcomplaintorinquiry.
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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(7100‐0135),Washington,
DC20503.
Signature: Date: