Complaint Form-Financial Institutions Division

COMPLAINT FORM Financial Institutions Division PLEASE COMPLETE THE COMPLAINT FORM, PRINT IT, SIGN IT, AND KEEP A COPY FOR YOUR RECORDS. RETURN IT BY MAIL TO: Nebraska Department of Banking & Finance Financial Institutions - Complaints P.O. Box 95006 Lincoln, Nebraska 68509-5006 GUIDELINES FOR COMPLETING THE COMPLAINT FORM Before filling out this form, please take the time to read these guidelines; they will help you understand our functions so that we, in turn, can serve you better. The Complaint Form may be completed using a computer (except for signatures) or by printing a copy of the form and typing or printing clearly in ink. After you have entered all necessary data, please sign and date the form and return it to the above address. WHAT WE CAN DO We investigate complaints against financial entities which are regulated by the Department under the laws of the State of Nebraska. Please refer to the Financial Institutions Page for the types of entities we regulate. We are empowered to bring administrative action if there are violations of the laws we administer, and, in appropriate cases, to refer matters to the proper authorities for further investigation and/or criminal prosecution. WHAT WE CANNOT DO We cannot act as a court of law to resolve factual disputes. If you have this type of problem, you should consult a private attorney. We cannot give legal advice or act as your attorney. If this dispute is the subject of a lawsuit, we cannot intervene in the matter. Sign the form and return it to the address above. Keep a copy for your files. Rev. 5-2011 1 American LegalNet, Inc. www.FormsWorkFlow.com SECTION I - CONSUMER INFORMATION Your name: (Last, First, MI) Your daytime phone: (include area code) Your street address: (if different from mailing address, please note) City: State: Zip code: Your email address if applicable: SECTION II - FINANCIAL ENTITY INFORMATION Name of financial entity: Street address: City: State: Zip code: Type of account in question: Savings Loan Account Checking Other:(explain) Account # :_______________________ Rev. 5-2011 2 American LegalNet, Inc. www.FormsWorkFlow.com SECTION III - NATURE OF THE PROBLEM Briefly describe the nature of your complaint and the events in the order in which they happened, including specific dates and the financial entity's actions to which you objected. Enclose COPIES of any pertinent information or correspondence that may be helpful. DO NOT SEND ORIGINALS; DO NOT SEND YOUR ONLY COPY OF ANY DOCUMENT. Keep a copy of this document for your own files. (If addi tional sp ace i s needed, pl ease attach a separate sheet, and reference it accordingly.) Have you attempted to resolve your complaint directly with the financial entity? "No" Please contact the financial entity and attempt to resolve your complaint BEFORE mailing this form. Name of person(s) contacted: Date(s) contacted: "Yes" Rev. 5-2011 3 American LegalNet, Inc. www.FormsWorkFlow.com Financial entity's response:(If additional space is needed, please attach a separate sheet.) PRIVACY STATEMENT The information requested on this form will be used to investigate and respond to your complaint. In our efforts to resolve your issue, this information may be disclosed outside of the agency to the financial entity which is the subject of your complaint; to any involved third parties; to the federal agency, if any, that has supervisory authority over the subject financial entity; to appropriate federal, state or local law enforcement authorities if a violation or possible violation of civil or criminal law is discovered; or to a legislative office in response to any inquiry made at your request. DISCLOSURE I wish to file a complaint against the financial entity named in this complaint form, with the understanding that the Department may conduct an investigation on my behalf. However, I understand that the Department does not have the authority to act as a judge in factual disputes. I understand that completion of this form is voluntary, but failure to provide requested information and/or failure to sign this form may delay or preclude investigation of my complaint. I understand that, as a part of the Department's investigation on my behalf, a copy of this form will be forwarded to the financial entity mentioned in the complaint. Signature Date: (required): Rev. 5-2011 4 American LegalNet, Inc. www.FormsWorkFlow.com