Full Name
Gender
Are you Hispanic/Latinx?
Race (check all that apply)
Are you eligible to declare veteran or military status?
Tell us about the problem. Check all that apply.
What product(s) do you have from the company? Check all that apply.
Do you have the contact information for anyone at this company that you spoke with?
Please share the contact information of the person you spoke to.
Date Contacted
Is there another company involved in the issue? For example, if you're having trouble with your mortgage due to defaulting on your student loans, it helps to know not just the name of your mortgage lender, but also the name of your student loan servicer.
Tell us about the second company that you would like help with.
Date contacted
In your own words, please describe the problem and any response from the company. Please explain the entire problem. It is important to include all details about the situation. Please be specific in referring to names, dates, or documents. If any part of the transaction occurred outside of the District of Columbia, please indicate that fact. Remember that it is better to include more information rather than less. You’re welcome to attach another page if needed. We also encourage you to attach copies of letters, invoices, contracts, emails, or other relevant documents. Do not send originals or your only copy of any document. Directions on how to submit those documents will be provided before you submit this form.
Do you believe that financial fraud or criminal activity has occurred?*
In addition to DC Government, there may be other government or private entities that can help you with your request. Have you contacted any of them? Some examples of these other entities are the U.S. Securities and Exchange Commission, the Office of the Comptroller of the Currency, Financial Industry Regulatory Authority, the US Department of Education, the Consumer Financial Protection Bureau, or your former school in the case of a student loan.
Do you have any supporting documents that would be helpful to share? Note: You can upload as many as 10 documents.
Supporting documents
Read and sign the following statements.
Privacy Statement: I understand that the information requested on this form will be used to investigate and respond to my complaint. In an effort to resolve my issue, this information may be disclosed outside the agency to the financial institution that is the subject of my complaint; to any involved third-parties; to other federal, state, or local agencies that have supervisory authority over the subject financial institution; to appropriate federal, state, or local law enforcement authorities; or to a legislative office if a complaint was initially or subsequently filed with such an office.
Disclaimer: I wish to file a complaint and/or raise a question concerning the financial institution named in this form with the understanding that the DISB may conduct an investigation on my behalf. However, I understand that the DISB does not have the authority to act and cannot act as my legal representative in connection with this complaint. I understand that my submission of this form is voluntary and that a failure to provide requested information and/or a failure to sign this form may delay or preclude the investigation of my complaint. I understand that as part of the DISB’s investigation, a copy of this form may be forwarded to the financial institution that is the subject of the complaint or other third-parties as referenced in the Privacy Statement above. I understand that DISB’s complaint process is not designed to replicate remedies available to me in a court of law.
Disclaimer: The Department of Insurance, Securities and Banking complies with all applicable federal and State laws regarding discrimination. The Commissioner does not base findings concerning complaints on a person’s age, ancestry, color, gender identity and expression, marital status, race, or any other protected status. In an effort to ascertain trends regarding complaint data, we ask that you voluntarily provide the requested demographic information. Demographic information will not be shared with the person or entity who is the subject of your complaint.
Authorization: I authorize the DC Department of Insurance, Securities and Banking to contact the subject financial institution on my behalf and access any relevant information that will assist in investigating my complaint.
Sign Here
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