Virginia Post Office Complaint Form Page 2

Details of complaint (use continuation sheet if additional space is needed)

What resolution are you seeking? How would you like your complaint resolved?

I authorize the Bureau of Financial Institutions to send a copy of this complaint, together with supporting documents, to

the company against which the complaint is filed, other regulated entities, or the appropriate state or federal agency. I

also authorize the company to release all records relating to this complaint to the Bureau of Financial Institutions, and I

authorize the Bureau of Financial Institutions to release records relating to this complaint to the company. I also agree

that by signing this form I authorize the Bureau of Financial Institutions to obtain any information required to evaluate

my complaint. Your signature is required for the Bureau to process your complaint.

Signature of complainant

Date signed

Print or type name

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