By the Division of Banks

Consumer Complaint Form

You may print this consumer complaint form as an Adobe Acrobat PDF file pdf format of compform.pdf
, download it as a Microsoft Word file doc format of compform.doc
, or select Print from your browser's File pull-down menu.

Mail or fax this completed complaint form with any attachments to:

Commonwealth of Massachusetts Division of Banks
Attn: Consumer Assistance Unit
1000 Washington Street, 10th floor
Boston, MA 02118-2218

Telephone: (617) 956-1500
Fax: (617) 956-1599



Credit Card, Federal Student Loan, Federal & National Banks, and Federal Credit Union complaints are to be directed to the Consumer Financial Protection Bureau (CFPB)

The CFPB was established by the Dodd-Frank Wall Street Reform and Consumer Protection Act of 2010. The CFPB conducts rule-making, and has supervision and enforcement for federal consumer financial protection laws.

 

Credit card complaint line: (855) 411-CFPB (2372)

Linea de asistencia para su tarjeta de crédito: (855) 411-CFPB (2372)

TTY/TDD: (855) 729-CFPB (2372)

CFPB credit card complaint form


Please Note:

  • The Division of Banks 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 where you are represented by an attorney, are in litigation, or have been litigated.
  • The Division of Banks cannot become involved in disputes between business entities and a financial institution.

YOUR INFORMATION


Salutation: Mr. __ Ms. __ Mrs. __ Other: ________________________________

First Name: _____________________________________ Middle Initial: ______

Last Name: ______________________________________________________

Street Address: ___________________________________________________

City: _____________________________ State: ________ ZIP: ______________

Home Phone: ___________________________________________________

Work Phone: ___________________________________________________

Email: __________________________________________________________

What is the best way to contact you? Phone __ Mail __ Email __

What is the best time to contact you? Morning __ Afternoon __ Evening __


ADDITIONAL CONTACT INFORMATION

If you want us to communicate with someone else, such as a family member or other person representing you about this complaint, then please provide your representative's information below. If you list someone else and sign this form, you allow us to communicate with and provide relevant information that is about you to that person.


Name of Representative: ____________________________________________

Relationship: _____________________________________________________

Street Address: ___________________________________________________

City: _____________________________ State: ________ ZIP: _____________

Phone: __________________________________________________________


FINANCIAL INSTITUTION OR COMPANY INFORMATION THAT IS SUBJECT OF THE COMPLAINT


Name of Financial Institution or Company: ______________________________

Street Address: ___________________________________________________

City: _____________________________ State: ________ ZIP: _____________

Phone: __________________________________________________________

Type of Complaint: ________________________________________________

Have you tried to resolve your complaint with your financial institution or company?

Yes __ No __

If Yes, When? _______________________________________

How? Phone __ Mail __ In Person __ Other ________________________

Contact Name: ____________________________________________

Title: ____________________________________________________

Have you filed a complaint or contacted another government agency?

Yes __ No ___

If Yes, 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). You should also include any response from the financial institution or company.

Be as brief and complete as possible to make the explanation clear. Use separate sheet(s) of paper if you need more space.

Please include COPIES of documents related to your complaint such as contracts, monthly statements, receipts and correspondence with the bank. DO NOT SEND ORIGINAL DOCUMENTS.



 


 


 


 


 


 


 


 


 


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?



 


 


 


 


 


I certify that the information provided on, or with, this form is true and correct to the best of my knowledge.


Signature: _______________________________________________________

Date: ___________________________________________________________