Each depositor insured to at least $250,000 per insured bank

OMB Number: 3064-0134 
Expiration Date: 8/31/2015
Customer Assistance Form
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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
 
Requester Information:
 
*Salutation   
Middle Name  
Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
Home Phone Number   
Work Phone Number    Cell Phone Number   
*Country  
  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
 
Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
Home Phone Number   
Work Phone Number    Cell Phone Number   
*Country  
 
 
Additional Contact Information:
 
Do you want us to communicate with another individual on your behalf, such as a family member, attorney, or other person representing you about this complaint? Yes  No
If you list someone you authorize us to communicate with the listed individual and provide information to that individual as well.
 
*Representative Last Name    *First Name   
Relationship    E-mail Address   
Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
Home Phone Number   
Work Phone Number    Cell Phone Number   
*Country  
 
Does your request involve a specific financial institution? Yes  No
 
*Country  
Phone numbers must be numeric, no dashes or parenthesis (ex:1234567890)
Type of account(s)   
Credit Card Checking Mortgage
Other  
 
MM/DD/YYYY   *How?   Phone  Mail  In Person  Other 
Contact Name    Title   
 
 
 
*Select one of the following that best describes your request:
 
 
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
1-877-ASK-FDIC (1-877-275-3342)
(Monday - Friday 8:00 am to 8:00 pm EST)
703-812-1020 (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.
 
 

FDIC 6422/04 (9-12)
Last Updated 09/21/2012 consumeralerts@fdic.gov