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Virginia Bureau of Financial Institutions Mailing Address: Telephone: (804) 371 - 9657 Post Office Box 640 Fax: (804) 371 - 9416 Richmond, VA 23218 - 0640 Web: www.scc.virginia.gov/bfi Physical Address: 1300 East Main Street, Suite 800, Richmond, VA 23219 PRINT OR TYPE all information in INK only. Keep a copy for your records. Return the completed form to the Bureau of Financial Institutions at the address shown above. PLEASE READ CAREFULLY . We are best able to assist you with your complaint if you do the following: Answer all questions in their entirety, giving full name, t itles, addresses and phone numbers. A summary of the facts surrounding the complaint and a statement of the desired resolution is necessary. Your signature is required for the Bureau to process your complaint. Attach copies of any letters, documents, co ntracts or receipts pertinent to your complaint. (PLEASE DO NOT SEND ORIGINALS). Mail or fax your complaint to the address indicated on the complaint form. Because of the complexity of some complaints, delays in processing do occur. We will make every effort to respond expeditiously to your complaint. Our authority is limited to those entities and individuals who are, or are required to be, chartered, licensed, registered, or otherwise subject to regulation or supervision by the State Corporation Co mmission. Name of Company Company Address City, State, Zip Code Name of person(s) you dealt with Telephone No. ( ) - Your Full Name Daytime Telephone No. ( ) - Your Address City, State, Zip Code Is your complaint currently the subject of pending litigation? Yes No Have you consulted legal counsel? Yes No Account/Loan No. Type of complaint: Checking Account Credit Card Payday Loan Consumer Loan Mortgage Loan Motor Vehicle Title Loan Other American LegalNet, Inc. www.FormsWorkFlow.com Details of complaint (use continuation sheet if additional space is needed) What resolution are you seeking? How would you like your complaint resolved? I authorize the Bureau of Financial Institutions to send a copy of this complaint, together with supporting documents, to the company against which the complaint is filed, other regulated entities, or the appropriate state or federal agency. I also author ize the company to release all records relating to this complaint to the Bureau of Financial Institutions, and I authorize the Bureau of Financial Institutions to release records relating to this complaint to the company. I also agree that by signing this form I authorize the Bureau of Financial Institutions to obtain any information required to evaluate my complaint. Your signature is required for the Bureau to process your complaint. Signature of complainant Date signed Print or type name American LegalNet, Inc. www.FormsWorkFlow.com