GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE BANKING COMPLAINT FORM Page 1 of 2 COMPLAINANT: Name: _______________________________________________________ Mailing Address: ______________________________________________ Telephone No.: (_____) ____________ (home)/ (_____) ____________ (Work) STATUS OF COMPLAINANT: COMPLAINT AGAINST: ACCOUNT TYPE: BANK CUSTOMER BANK EMPLOYEE BORROWER TRUSTEE OTHER _____________________________________ BRANCH MANAGER  BANK LOAN CLERK CONSULTANT OTHER___________________________________ Indicate Individual’s/Company’s Name: _____________________________ Telephone No.: (_____) ____________ Facsimile No.: (_____) __________ SAVINGS PERSONAL LOAN COMERCIAL LOAN CHECKING AUTO LOAN MORTGAGE OTHER________________________________________________ Complaint No. ______________ Date Received: ______________ Date Resolved: ______________ Page 2 of 2 1131 King Street, Suite 101, Christiansted, VI 00820 • Tel: (340) 773-6459 • Fax: (340)719-3801 REASON FOR COMPLAINT: SUMMARY/REASON FOR COMPLAINT: __________________________________ _____________________ Signature Date EXAMINER’S FINDINGS: ____________________________________ ______________________ Signature Date INTEREST RATES MISREPRESENTATION UNEARNED INTEREST SERVICE CLOSING OF ACCOUNTS LOAN BALANCE CANCELLATION WITHOUT WRITTEN NOTICIFICATION DENIAL OF LOAN OTHER ______________________________ Hearing Requested By: _______________________ Hearing Date: ____________ Notice of Penalty: ____________________ Penalty Imposed: __________________ Court Action: _______________________ Date: __________________________