State of New York

Consumer Services Division

Banking Department
One State Street
New York, N.Y. 10004-1511
Complaint Form
1. PLEASE BE SURE TO COMPLAIN TO THE INSTITUTION OR INDIVIDUAL
BEFORE FILING.
2. PLEASE TYPE OR PRINT CLEARLY IN DARK INK.
3. INCOMPLETE OR UNCLEAR FORMS WILL BE RETURNED TO YOU.
4. MAKE SURE YOU ENCLOSE COPIES OF IMPORTANT PAPERS CONCERNING
YOUR TRANSACTION.

Complainant
Your Name Home Tel.

Street Address Bus. Tel.

City / Town State Zip Code+4

Respondent Information
Name of Bank or Financial Institution Your Account Number (If Any)

Street Address What Relief are You Seeking?

City / Town Approximate Dollar Amount Involved

Telephone Date of Transaction

Type of Complaint - e.g., check cashing, deposits, withdrawals, etc. (Use reverse to provide details):

Date You Complained to Institution Person Contacted

By Telephone By Mail In Person

Nature of Response Date of Response

Has this matter been submitted by another agency or attorney? Yes or No If yes, give name and address.

Is court action pending? Yes or No

PLEASE DESCRIBE COMPLAINT ON REVERSE SIDE

Contact: (877) BANK-NYS or (212) 709-3530 or (212) 709-3582 Fax: (212) 709-1673
Briefly describe your complaint:

What form of relief are you seeking?

Who referred you to this office?

READ THE FOLLOWING BEFORE SIGNING BELOW:

PLEASE ATTACH TO THIS FORM PHOTOCOPIES OF ANY PAPERS INVOLVED (CONTRACTS,
BILLS, CANCELLED CHECKS, CORRESPONDENCE, ETC.) DO NOT SEND ORIGINALS.

NOTE: In order to resolve your complaint we may send a copy of this form to the person or firm you are complaining about.

In filling this complaint, I understand that the Banking Department is not my private attorney, but represents the public in
enforcing laws designed to protect the public from misleading or unlawful business practices. I also understand that if I have any
questions concerning my legal rights or responsibilities, I should contact a private attorney. I have no objection to the contents of
this complaint being forwarded to the institution or person the complaint is directed against. The above complaint is true and
accurate to the best of my knowledge.

Signature Date

HAVE YOU ENCLOSED COPIES OF IMPORTANT PAPERS?

NYSBD Form 38-0004, January 2009