Which financial service provider is the complaint about?: *

Account or customer name (if available):

Account or customer number (if available):

Complaint number (if available):

Deadlock number (if available):

What is your complaint about?: *

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Attach file:

Attach file:

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Have you made the complaint to the financial service provider concerned?: *YesNo

Have you made this complaint to any other authority?: YesNo

Your name: *

Complainant name:

(If different from above i.e: if you are making a complaint on behalf of someone else)

E-mail: *

Address:

Phone:

Mobile:

Fax:

Please select: *Yes, I authorise my Scheme Member to release my information to FDRC.

Please select: *Yes, I understand that the maximum compensation that FDRC can award is $200,000, and by submitting this complaint I agree to waive my rights to any amount in excess of $200,000.