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OMB Number: 0164-013 
Expiration Date: 4/30/2009
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.
Requester Information:
Middle Name  
Home Phone Number   
Work Phone Number    Cell Phone Number   
  What is the best way to contact you?    Phone    Mail    Email
  What is the best time to contact you?    Morning    Afternoon    Evening
If this request is submitted on behalf of you and another individual, complete this section:
Home Phone Number   
Work Phone Number    Cell Phone Number   
Additional Contact Information:
If 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, then please provide their contact information below. 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   
Home Phone Number   
Work Phone Number    Cell Phone Number   
If your request involves a specific financial institution, complete the following information:
Type of account(s)   
Credit Card Checking Mortgage
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
2345 Grand Boulevard, Suite 100
Kansas City, MO 64108
(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 (10-05)
Last Updated 07/27/2007

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