DFPI 801 - Consumer Complaint Form ver. 08-24

STATE OF CALIFORNIA - DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

CONSUMER COMPLAINT FORM

DFPI-801 (Rev. 08-23)

Thank you for submitting a consumer complaint to the Department of Financial Protection and Innovation. By

informing us of potentially improper or illegal activity in the financial services marketplace, your input helps

us protect you and other Californians.

By submitting this complaint, you certify the information provided is true and correct to the best of your knowledge

and consent to allow the subject of the complaint and its affiliates to disclose to the Department any information the

Department deems relevant to your complaint, including your transactions, accounts, and other experiences with

them. If you are submitting this complaint on behalf of another person, you certify under penalty of perjury you are

authorized to submit this complaint on that person’s behalf.

The Department uses consumer complaint information to investigate potential violations of law. In general, consumer

complaints are considered to have been received by the Department in confidence. However, Civil Code section

1798.24 allows the Department to disclose your personal information with another person or governmental

organization to the extent needed to obtain information for our investigation of a failure to comply with our laws. It

also allows the Department to disclose your information with other self-regulatory organizations and government

agencies, including federal and state financial services regulators and law enforcement agencies, if certain conditions

are met and subject to limitations.

In addition, you may consent to the Department’s disclosure of your personal information for reasons other than

those set forth in Civil Code section 1798.24 (for example, to allow the Department to forward your personal

information to the subject of your complaint when an investigation by the Department is not needed). If you consent

to the Department’s disclosure of your personal information for these other reasons, please mark the box below:

I do not consent to the Department’s sharing of my personal information for reasons other than those set

forth in Civil Code section 1798.24 and understand this could prevent the Department from resolving my

complaint.

Your Information (type or print clearly):

(We collect the following information so we can contact you for follow-up information and to determine who else

may be affected by the issue raised in your complaint.)

__________________________________________________________________________________________________

Full Name (First, MI, Last)

__________________________________________________________________________________________________

Address (Street, City, State and ZIP Code)

__________________________________________________________________________________________________

Property Address (Street, City, State and ZIP Code)

_________________________________________________

_______________________________________________

Daytime Phone Number

E-Mail Address

I consent to the Department’s disclosure of my personal information (including my name and financial

matters) with the subject of my complaint, with other governmental or quasi-governmental agencies, and with

self-regulatory organizations, to the extent the disclosure is needed to help resolve my complaint. This consent

is valid for two years from the date my complaint is received by the Department. After those two years have

elapsed, the Department will need to obtain a new consent from me to disclose my personal information for

reasons other than those set forth in Civil Code section 1798.24.

Does your complaint involve Crypto or digital asset?

Your age (optional):

Are you currently in the United States Military?

How did you hear about us?

☐ 18-24

☐ Under 18

☐ Billboards

☐ Social media

☐ Other

☐ Radio

Yes

☐ No

☐

25-34 ☐ 35-44

☐ 45-54 ☐ 55-61 ☐ 62+

☐ Decline to Answer

☐ Yes

(Branch:______________________) ☐ No

☐ News/media reports

STATE OF CALIFORNIA - DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

CONSUMER COMPLAINT FORM

DFPI-801 (Rev. 08-23) Page 2 of 4

Information on the individual or organization about which you have a complaint:

__________________________________________________________________________________________________

Full Name of Financial Institution, Business, Company, Firm, or Person

__________________________________________________________________________________________________

Business Address (include Room #, Suite #, or Apt. #), City, State, ZIP Code

__________________________ ____________________________________________________________________

Business Phone

Full Name of Salesp

erson, Agent or Other Representative (if applicable)

Have you contacted the financial institution, business, firm or individual(s) regarding your complaint?

☐Yes ☐No

If yes, include names, dat

es, and results of your contact(s) in #4 below. Attach copies of all related documents.

Describe your complaint. Please clearly describe the events in the order in which they occurred. Include full names,

addresses, a description of the problem with the amount(s), date(s) of any transaction(s), contact information of any

witnesses to the transactions, and any other relevant information that may assist us in resolving your complaint. Finally,

please state if you have filed a lawsuit or arbitration for this complaint. For your protection, DO NOT INCLUDE PERSONAL

CONFIDENTIAL INFORMATION SUCH AS YOUR SOCIAL SECURITY NUMBER. Include extra pages as necessary.

__________________________________________________________________________________________________

What do you believe would be a fair resolution to this matter?

_________________________________________________________________________________________________

STATE OF CALIFORNIA - DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

CONSUMER COMPLAINT FORM

DFPI-801 (Rev. 08-23) Page 3 of 4

How We Can He

lp You:

Submit this complaint form if you believe any person or entity doing business with Californians or located in California has

violated a law administered by the Department of Financial Protection and Innovation. This includes those who may be

conducting unlicensed or unregistered activity within the Department’s jurisdiction or those who may have committed unlawful,

unfair, deceptive, or abusive acts and practices with respect to financial products or services.

Complaints submitted to the Department will be reviewed to determine whether an investigation and possible enforcement

action may be warranted. Please do not, however, consider a complaint to the Department as a substitute for pursuing your

own private legal remedies. The Department cannot give you legal advice so please consult a private attorney if money

needs to be recovered or a contract needs to be cancelled.

If your complaint is not within our jurisdiction, we may refer your complaint to the appropriate agency and provide you with a

copy of the referral.

Before You Submit a Complaint, Here’s What We Need:

• Completed Complaint Form. Please type or print clearly in ink.

•

Copies of all documentation. Please do not send originals.

About the Department of Financial Protection and Innovation:

The Department of Financial Protection and Innovation (DFPI) regulates a variety of financial services, products, transactions,

and professionals. For more information about the industries and the financial services and products regulated by the

DFPI, please visit https://dfpi.ca.gov/licensees-and-regulated-industries/ and

https://dfpi.ca.gov/california-consumer-

financial-protection-law/.

The Department of Financial Protection and Innovation will

provide you with written confirmation we received this form.

If you have questions or need assistance filling out this

form, please call

the Department of Financial Protection and Innovation’s

Consumer Services Office toll-free at

866-275-2677

Mail the form and a copy of all documentation to:

Department of Financial Protection and Innovation

Attn: Consumer Services Office

2101 Arena Blvd.

Sacramento, CA 95834

STATE OF CALIFORNIA - DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

CONSUMER COMPLAINT FORM

DFPI-801 (Rev. 08-23) Page 4 of 4

PRIVACY NOTICE

The following notice is required by state law under the Information Practices Act of 1977 (California Civil Code Section

1798.17).

DFPI Collects and Uses Personal Information: The California Department of Financial Protection and Innovation

collects the information requested in the attached form as authorized by the Financial Code and Chapters 1 and 3 of

Title 10 of the California Code of Regulations. In addition to using this information to take appropriate action against

the subject of your complaint, the DFPI may also use the information to determine whether:

•

A license, qualification, registration, certificate, or other authority should be accepted, granted,

approved, denied, revoked, or limited in any way;

•

Business entities or individuals regulated by the DFPI are conducting themselves in accordance with

applicable laws; and/or

•

Laws administered by the DFPI are being or have been violated and whether administrative action, civil

action, or referral to a self-regulatory organization or other government agency is appropriate.

The Commissioner is responsible for the performance of all duties, the exercise of all powers and jurisdiction, and the

assumption and discharge of all responsibilities vested by law in the DFPI. The Commissioner has and may exercise all

the powers necessary or convenient for the administration and enforcement of, among other laws, the laws described in

Financial Code section 300. The Commissioner may issue such rules and regulations consistent with law as he or she

may deem necessary or advisable in executing the powers, duties, and responsibilities of the DFPI.

The information you provide is maintained by the DFPI pursuant to one or more of the following laws:

•

California Consumer Financial Protection Law (Financial Code section 90000, et seq.);

•

Debt Collection Licensing Act (Financial Code section 100000, et seq.);

•

Student Loan Servicing Act (Financial Code section 28100, et seq.);

•

Corporate Securities Law of 1968 (Corporations Code section 25000, et seq.);

•

Capital Access Company Law (Corporations Code section 28000, et seq.);

•

Bucket Shop Law (Corporations Code section 29000, et seq.);

•

California Commodity Law of 1990 (Corporations Code section 29500, et seq.);

•

Franchise Investment Law (Corporations Code section 31000, et seq.);

•

Financial Institutions Law (Financial Code section 99, et seq.);

•

Money Transmission Act (Financial Code section 2000, et seq.);

•

Check Sellers, Bill Payers and Proraters Law (Financial Code section 12000, et seq.);

•

California Credit Union Law (Financial Code section 14000, et seq.);

•

California Deferred Deposit Transaction Law (Financial Code section 23000, et seq.);

•

Escrow Law (Financial Code section 17000, et seq.);

•

California Financing Law (Financial Code section 22000, et seq.);

•

Securities Depository Law (Financial Code section 30000, et seq.); and

•

California Residential Mortgage Lending Act (Financial Code section 50000, et seq.).

Providing Personal Information is Not Mandatory: All information you provide is voluntary. You are not required to

provide personal information, such as your name, Social Security number, physical description, home address, home

telephone number, education, financial matters, and medical or employment history. Please do not provide personal

information unless the DFPI requests it.

DFPI May Disclose Your Personal Information: Without your consent, we may share your personal information to the

extent allowed by Civil Code section 1798.24. This includes sharing your personal information with another person or

governmental organization to the extent needed to obtain information for our investigation of a failure to comply with our

laws. This also includes sharing your information with other self-regulatory organizations and government agencies,

including federal and state f

inancial services regulators and law enforcement agencies, if certain conditions are met and

subject to limitations.

Your Access to Your Personal Information: You have a right to see your personal information maintained by the

DFPI. To request access, please contact:

Department of Financial Protection and Innovation

2101 Arena Blvd.

Sacramento, Californi

a 95834

(866) 275-2677

https://dfpi.ca.gov/pra-request/