Washington State Department of Financial Institutions

Payday Loan Complaint Form

Before you begin, please review instructions on how to file a complaint with the Division of Consumer Services.

* Denotes a required field

Your Information and Description of Problem

Public Records Disclosure Act:

The Washington Public Records Act (PRA), RCW 42.56, may require disclosure of a complaint after a file is closed. If you choose, you may keep your identifying information exempt from disclosure under the PRA by checking this box. Please note that this exemption does not necessarily restrict the release of your identifying information pursuant to a court order, subpoena, or during litigation.

* Name(s)
* Mail Address
* City * State
* Zip
* Phone
Cell Work
Email

* Is your home address different than the mailing address listed above?
Yes No

Home Address
City State  
Zip

* Are you on activity duty in the armed forces or a dependent?
Yes No

* Provide A Concise Description Of The Problem

Attorney Information

* Do you have an attorney?
I do not have an attorney
I have an attorney

I would like you to work directly with my attorney
Attorney Name
Firm
Address
City State
Zip
Phone
Fax
Email

About the Payday Loan Company

Information about the company you have disputed transaction(s) with.

* Name(s) of lender
Email address(es)
used or provided by company
* Physical addresses
used or provided by company
Website address(es)
Used to obtain the loan
Did you talk to any employees? Yes No

Who did you talk to at the payday loan company?

Name(s)
Title(s)
Date(s) of discussion
Did you get a business card? Yes No
a) Can you provide a copy of the business card?
Yes No
Please provide any other details of your conversation. What did they say?

Disputed Payday Loan Transaction Details

* Date of disputed transaction
(month/day/year)

Questions

1) Did you complete an application? Yes No
a) Can you provide a copy of the application?
Yes No
b) Comments about the application
2) Did you complete a loan agreement? Yes No
a) Can you provide a copy of the agreement?
Yes No
b) Comments about the loan agreement
3) Did you complete any other forms? Yes No
a) Can you provide a copy of the other forms?
Yes No
b) Comments about the other forms
4) Did you receive any other paperwork? Yes No
a) Can you provide a copy of the other disclosures?
Yes No
b) Comments about the other forms
5) Did anyone explain or discuss the terms
of the loan with you? 		Yes No
a) What did they say?
6) How did you receive the loan funds?
7) How were you supposed to pay
the company back? (ACH, direct
withdrawal, cash, postdated check, etc.)
8) Did they ask you to pay with
more than one check?		 Yes No
How many?
Amount $
Can you provide check copies?
Yes No

Disputed Payday Loan Transaction History

Transaction 1

Payday Loan Company Name
Can you provide a copy of your loan documents?
Yes No
Transaction Date Loan Amount
(before fees)		 Fees Paid Did you default?
$ $ Yes No

Transaction 2

Payday Loan Company Name
Can you provide a copy of your loan documents?
Yes No
Transaction Date Loan Amount
(before fees)		 Fees Paid Did you default?
$ $ Yes No

Transaction 3

Payday Loan Company Name
Can you provide a copy of your loan documents?
Yes No
Transaction Date Loan Amount
(before fees)		 Fees Paid Did you default?
$ $ Yes No

Payment Plan/Installment Plan Details

Did you request a payment plan?
Yes No
Did you obtain a payment plan?
Yes No
a) Date you obtained payment plan
b) What were the terms of the payment plan?
c) Did they ask for more than one check from you to start the payment plan?
Yes No
i) How many?
ii) Amount $
iii) Can you provide us a copy of the checks?
Yes No
d) Did you enter into a contract for the payment plan?
Yes No
i) Can you provide us a copy?
Yes No

Other Fees

Did you pay any other fees related to the payment plan (such as insufficient funds, or attorney fees?
Yes No
a) Can you provide us a copy of the checks and notices?
Yes No
b) How much were the fees and what were they for?
Amount $
Reason(s)

Collection Questions

1) Are you or have you ever been delinquent with payments to this company?
Yes No
a) When? (Date)
b) Who contacted you? How did they contact you? How did they identify themselves?
2) Did you ever receive a written notice or letter for being delinquent on your loan(s)?
Yes No
a) If yes, can you provide a copy of this information?
Yes No
3) Did they threaten you (i.e. threaten criminal charges, says you were guilty of fraud, say you would be arrested, etc?)
Yes No
a) How did they threaten you (i.e. during phone calls, in person, or in writing)?


b) What did they say?
4) Do you have any logs or records of the calls or correspondence?
Yes No
a) Can you provide us a copy of the logs or records?
Yes No
5) Were you taken to small claims court?
Yes No
a) What was the case number and what was the result
6) Do you know of anyone else (friends, family) who could provide us with additional information regarding this company?
Yes No
a) Provide names and relationship to this person and their contact information (1 per line, please)
7) Is there anything else you would like to tell us about your experience(s) with this company?

Declaration

By filling in my name and the 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.

* Name
* Date

DFI