Mortgage, Consumer Loan, and Student Education Loan Complaint Form

Public records disclosure

Your complaint is a public record under the Washington State Public Records Act (RCW 42.56). Your complaint may be released if someone requests it. If you provide identifying information in your complaint, your complaint is not anonymous.

We may release your identifying information (including your name and contact information). You can choose to have your identifying information removed. Please note that this does not stop the release of your information as part of a court case or subpoena.

Release information? *

Do not release my identifying information in response to a request for public records

It’s OK to release my identifying information in response to a request for public records

Your information

Full name(s) *

Mailing Address *

City *

State *

Zip Code *

Residence Address (If Different)

Please tell us where you live if it’s different than where you get your mail

City

State

Zip Code

Telephone *

Email address *

How should we send you updates about your complaint? *

Email

US Mail

Are you on active duty in the armed forces, or a dependent of someone who is? *

Yes

No

Are you submitting this complaint for someone else?

Yes

No

If you are submitting this complaint for someone else, do you have that person’s permission to communicate with us about their complaint?

We’ll need that person’s written, signed permission to communicate with you about the complaint.

Yes

No

Has this matter been submitted to another agency or attorney?

Yes

No

If you are not a party to the transaction described in the complaint, what is your involvement?

Do you have an attoney?

Yes

No

Is a court action pending for this matter?

Yes

No

Would you like us to send correspondence about your complaint to your attorney?

If you choose yes, we will communicate with you through your attorney, rather than with you directly.

Yes

No

Attorney's name

Name of law firm

Address

City

State

Zip

Telephone

Email

If you want us to contact your attorney, how should we contact them?

Email

US Mail

What Happened?

Against whom are you filing a complaint?

Name(s) *

Address

City

State

Zip

Telephone

Email Address

Who You Contacted

Type of Transaction

When Did The Transaction Occur?

Year

Month

Day

Student Education Loan (SEL) Information

Was this transaction related to an Student Education Loan?

If yes, was the transaction related to a modification of your Student Education Loan?

If yes, was the modification by the same company you regularly make payments to?

Yes

No

Mortgage Information

Does your complaint involve a mortgage?

Yes

No

Was this property your primary residence at the time the loan was originated?

Yes

No

Is this property currently your primary residence?

Yes

No

If no, is it:

Investment property?

Rental property?

Commercial property?

Manufactured/mobile property?

Loan Modification Services Information

Did you pay for loan modification services?

Yes

No

Total cost $

Amount of any upfront payment (the amount you paid before accepting a loan modification offer)

Method of payment

Other form of payment

Did you sign a contract?

Yes

No

Date signed

Year

Month

Day

Was the product or service advertised?

Yes

No

Date advertised

Year

Month

Day

How was it advertised?

Mail

Website

Phone

Other

Other form of advertisement

What services did the company offer to provide?

Interest Rate Reduction

Principal Reduction

Term Extension

Other

Other services company offered

Did the company provide a guarantee?

Yes

No

In what time frame did the company guarantee you this result?

Were you satisfied with the result?

Yes

No

Method of complaint to the company or individual

Other method of complaint

Did you request a refund?

Yes

No

Did you receive a loan modification?

Yes

No

Complaint/Problem

Provide a description of the problem (remember to include: who, what, when, why and how the event transpired.) *

Can you provide copies of documents relevant to the complaint?

Yes

No

Have you tried to resolve your complaint?

Yes

No

Date(s) of Contact

Method of Contact

Phone

Mail

In Person

Other

Other Method of Contact

Who You Contacted

Phone of person you contacted

Have you filed a complaint or contacted another government agency?

Yes

No

Agency Name

Results of that complaint

What do you think will resolve this problem for you?

How did you hear about DFI?

Declaration

By filling in my name and date below, I declare, under penalty of perjury under the laws of the State of Washington that the information contained in this complaint is true and accurate and the information may be used to further investigate the complaint.

Full Name *

Date *