This form should be used only by regulated financial entities.

Please use the form below to email us your emergency contact information.

The Division of Banks cannot guarantee the security of emergency contact information submitted through the internet. Please see our Privacy Policy for more information.

If you are uncomfortable using the internet to submit your emergency contact information, please print the forms when complete and attach them to a signed letter on your institution's letterhead and mail to:

Massachusetts Division of Banks
1000 Washington Street, 10th Floor
Boston, MA 02118-6400

attn: Bernard N. Waxman

Alternatively, the printed forms may be faxed to the attention of Bernard N. Waxman at 617-368-2496.

If you have any questions please call Bernard N. Waxman at 617-521-7581.

When you are done, be sure to hit the SEND button at the bottom of the form.

Emergency Contact Information:

 		 
Your Name:

Title:

Institution Name:

Certification or Federal Tax ID Number (required, no spaces or hyphens):

Email Address (required):


(Please enter your correct email address here!!)

Telephone:

FAX:


 
My financial institution is a Bank Credit Union Licensee

When you are finished, press the Send button.