Consumer Complaint Form (Page 2 of 3) in pdf

Consumer Complaint Form Page 2

CONSUMER COMPLAINT FORM (Page 2)

Institution Information (Who you are filing a complaint against):

Name of Institution:

Address:

Street

City

State

Zip

Type of Account:

Account #:

Have you tried to resolve your complaint with the Institution?

Yes

If Yes, when?

How?

Phone

Mail

In Person

Other

If you have an attorney or other representative you want us to deal with directly, please provide your

representative's information below. Your signature on this form authorizes your institution and our

office to release information to your representative.

Name of Representative:

Title:

Address:

Street

City

State

Zip

Daytime Phone:

(

)

Ext:

Fax:

(

)

Please print or type your complaint. 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 institution.

Be brief but as complete as necessary to make the explanation clear. Use separate sheet(s) of

8.5” x 11” paper if you need more space.

State of Utah

Department of Financial Institutions

Page 2 of 3

Consumer Complaint Form Page 2