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STATE OF CALIFORNIA -DEPARTMENT OF BUSINESS OVERSIGHT CONSUMER COMPLAINT FORM DBO-801 (Rev. 12-17) Thank you for taking time to submit a consumer complaint to the Department of Business Oversight. By informing us of potentially improper or illegal activity in the financial services marketplace, your input helps us protect you and other Californians. 1.Your Information (type or print clearly):(We collect the following information so that we can contact you for follow up information and to determinewho else may be affected by the issue raised in your complaint.)Full Name (First, MI, Last) Address (Street, City, State and Zip Code) Daytime Phone Number E-Mail AddressWhat is the best way to contact you? Phone Mail E-mailYour age (optional): Under 30 3050 50 and OverAre you currently in the United States Military? Yes (Branch: ) No 2.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 Salesperson, Agent or Other Representative (if applicable) 3.Have you contacted the financial institution, business, firm or individual(s) regarding your complaint?Yes No If yes, include names, dates and results of your contact(s) in #4 below. Attach copies of all related documents. 4.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) and the contact information of anywitnesses 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 PERSONALCONFIDENTIAL INFORMATION SUCH AS YOUR SOCIAL SECURITY NUMBER. Include extra pages as necessary.5.What do you believe would be a fair resolution to this matter?In submitting this complaint, you agree the information provided is true and correct to the best of your knowledge and that the information may be used by the Department for its investigation. Consumer complaints are considered to have been received by the Department in confidence. However, the Department may, at its sole discretion, disclose your complaint to the person or entity for the purpose of corrective action. The Department may also choose to disclose your complaint to others for the purpose of facilitating an investigation of the person or entity complained against or initiating legal proceedings against the same under the investigation. American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA -DEPARTMENT OF BUSINESS OVERSIGHT CONSUMER COMPLAINT FORM DBO-801 (Rev. 12-17) Page 2 of 4 Mail the form and a copy of all documentation to: The Department of Business Oversight will contact you shortly Department of Business Oversight after receipt of this form. If you have questions or need Attn: Consumer Services Office assistance filling out this form, please call the Department of 1515 K Street, Suite 200 Business Oversights Consumer Services Office toll-free at Sacramento, CA 95814 866-275-2677 How We Can Help You: If you believe a licensee of the Department of Business Oversight has acted improperly, or a company or person is conducting unlicensed activity , please submit a complaint form. Complaints submitted to the Department are 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 private legal remedies. The Department is unable to give you legal advice so please consult a private attorney if money needs to be recovered or a contract needs to be cancelled. The Department does not have the statutory authority to award damages, overturn fines or other charges. The Department is unable to become involved in complaints that are in litigation or have been litigated. The Department values your privacy. Complaints filed with the Department are generally confidential, however depending on the nature of the complaint, particularly against licensed financial institutions and other lenders, the Department may share certain information to resolve the matter. Complaints regarding unlicensed activity are kept confidential. We strongly encourage any member of the public to file a complaint if they believe a licensee has engaged in wrongful activity. If your privacy is of concern, please note that in the description of your complaint. If a written complaint is submitted to the Department that is not within our jurisdiction, we will refer the complaint to the appropriate agency and provide you a copy of the referral so your issue may be dealt with by the appropriate regulatory agency. Before You Submit a Complaint, Heres 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 Business Oversight: The Department of Business Oversight (DBO) provides protection to consumers and services to businesses engaged in financial transactions. The Department regulates a variety of financial services, products, transactions and professionals, including: State-Chartered Banks Finance lenders, mortgage loan servicers, and Bill payers, check sellers, and proraters (consumer certain mortgage lenders and mortgage brokers credit counselors, debt management companies) Foreign (Other State and Other Nation) Banks Business and Industrial Development Corporations State-Chartered Industrial Banks State-Chartered Credit Unions Local Agency Security Program (LASP) Independent Escrow companies and agents. Money Transmitters Premium Finance Companies Offer and Sale of Securities Securities professionals (broker-dealers, investment Offer and Sale of Franchises advisers, financial planners) Payday lenders Trust Companies and Departments For more information about licensees of DBO, please visit www.dbo.ca.gov. American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA -DEPARTMENT OF BUSINESS OVERSIGHT CONSUMER COMPLAINT FORM DBO-801 (Rev. 12-17) Page 3 of 4 NOTICE REQUIRED UNDER STATE LAW The following notice is required by state law under the Information Practices Act of 1977 (California Civil Code Section 1798.17). The California Department of Business Oversight requests the information in the attached form 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 licensed or otherwise regulated by the Department of Business Oversight are conducting themselves in accordance with applicable laws; and/or Laws administered by the Department of Business Oversight 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. All information you provide is voluntary. Failure to provide all or any part of the information requested may hinder the Department of Business Oversight from investigating your complaint. We may share your personal information, as needed, with licensed business entities or individuals to facilitate resolution of your complaint. We may also share your information with other government agencies or self-regulatory organizations. 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 Department. 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 Department. The information you provide is maintained by the Department of Business Overs