Fdic Complaint Form
Fdic Complaint Form
Fdic Complaint Form
Each depositor insured to at least $250,000 per insured bank
OMB Number: 30640134
Expiration Date: 8/31/2015
Customer Assistance Form
Privacy Act Statement Paperwork Reduction Act Notice
Please complete this form if you have a question regarding FDIC deposit insurance coverage, or an inquiry or a
complaint regarding your financial institution. Once the form has been submitted you will receive the Customer
Assistance Confirmation page indicating that your request has been received.
Please note that if you have a complaint:
We cannot act as a court of law or as a lawyer on your behalf.
We cannot give you legal or financial advice.
We cannot become actively involved in complaints that are in litigation or have been litigated.
* Required
Fields
*Indicate whether you are a: Consumer OR Banker
Requester Information:
*Salutation Please Select
*First
*Last Name
Name
Middle Name
*Email
Address
*Confirm Email
Address
Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
Home Phone
Work Phone Number Cell Phone Number
Number
*Street
Address, line 1
Street Address,
line 2
*City *State Please Select *Zip Zip Ext
*Country United States
What is the best way to contact you? Phone Mail Email
What is the best time to contact you? Morning Afternoon Evening
Is this request submitted on behalf of you and another individual? Yes No
*First
*Last Name
Name
Email Address
Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
Home Phone Work Phone Number Cell Phone Number
Number
Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
Home Phone
Work Phone Number Cell Phone Number
Number
*Street
Address, line 1
Street Address,
line 2
*City *State Please Select *Zip Zip Ext
*Country
Does your request involve a specific financial institution? Yes No
*Institution
Name
Street Address,
Line 1
Street Address,
Line 2
*City *State Please Select Zip Zip Ext
*Country
Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
Phone Number
Type of
account(s) Credit Card Checking Mortgage Other
Have you tried to resolve your complaint with your financial institution or company? Yes No
Contact Name
Title
Have you filed a complaint or contacted another government agency? Yes No
*Agency
Name?
*Select one of the following that best describes your request:
Complaint Deposit Insurance Inquiry Other Inquiry
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). Do not include personal or confidential information such as
your social security, credit card, or bank account numbers. If you need to provide COPIES of any supporting
documentation such as contracts, monthly statements, receipts or any correspondence with the bank (do not send original
documents), you may mail or fax this information to:
FDIC Consumer Response Center
1100 Walnut Street, Box #11
Kansas City, MO 64106
1877ASKFDIC (18772753342)
(Monday Friday 8:00 am to 8:00 pm EST)
7038121020 (Fax number)
*Please describe below the nature of your complaint or inquiry.
Use single quote marks rather than double quotes, if any.
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?
*Checking this box authorizes the FDIC to respond and investigate (if applicable) your concerns.
Send Clear Print
FDIC 6422/04 (912)
Last Updated 09/21/2012 consumeralerts@fdic.gov