Customer Complaint Form Page 3
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3CUSTOMER COMPLAINT FORM (Page 3)
State your desired resolution:
PRIVACY ACT STATEMENT
The solicitation and collection of this information is authorized by 15 U.S.C. § 57a(f) and 12 U.S.C. 1 et
seq. The information is solicited to provide the Office of the Comptroller of the Currency (OCC) with
data that is necessary and useful in reviewing requests received from individuals for assistance in their
interactions with national banks. The provision of requested information is voluntary. However, without
such information, the ability to complete a review or to provide requested assistance may be hindered.
It is intended that the information obtained through this solicitation will be used within the OCC and
provided to the national bank that is the subject of the complaint or inquiry. Additional disclosures of
such information may be made to: (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 having: (a) jurisdiction over the subject
matter of the complaint or inquiry; (b) 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 or
licensing standard for which another organization has jurisdiction; (3) 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; (4) a Congressional office when the information is relevant to an inquiry
initiated on behalf of its provider; (5) OCC contractors or agents when access to such information is
necessary; and (6) other third parties when required or authorized by statute.
I certify that the information provided on, or with, this form is true and correct to the best of my
knowledge.
Date:
Signature:
We will mail you a written acknowledgment within five (5) business days of receipt of your completed
complaint form. If you have any questions regarding this case, please call 1-800-613-6743.
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