Fillable Printable Financial Ombudsman Service Dispute Form
Fillable Printable Financial Ombudsman Service Dispute Form
Financial Ombudsman Service Dispute Form
Before the Financial Ombudsman Service can consider your dispute, you need to
have complained to the Financial Services Provider and given it an opportunity to
resolve your dispute. In most cases, it has 45 days to respond.
Have you previously lodged or ‘registered’ this dispute with us?
Yes, I have previously lodged or registered this dispute with the Financial
Ombudsman Service. The case number is
No, this is the first time I have lodged or registered this dispute with the Financial
Ombudsman Service.
This section should be completed with the details of the Applicant(s). The Applicant is
the person who is in dispute with the Financial Services Provider (usually the
customer). If the Applicant is a company or association, the form must be completed
by someone who is authorised to act on behalf of the company or association.
Applicant 1 Applicant 2
First name Title Title
Middle initial
Family name
Date of birth
Postal
address
State Postcode
Mobile
Home
phone
( )
Email
Work
phone
( )
Please tick here if one or more of the Applicants identifies as being of Aboriginal and/or
Torres Strait Islander origin
Are you lodging the dispute on behalf of a business?
Yes
No
Business
name
ABN
How many employees did the business have at the time of the
event(s) giving riseto the dispute?
Applicant
details
Action to date
Dispute Form
This section should only be completed if you wish to appoint someone to act on
your behalf in dealing with us.
If you appoint a representative, the representative and any organisation they work for
will be our point of contact and will be sent all correspondence related to your dispute.
The Financial Ombudsman Service provides a free service. There is no need for an
Applicant to be represented. Where an Applicant chooses to be represented by
another party, any cost incurred through this representation will usually be the
responsibility of the Applicant.
First name
Title
Family name
Relationship to you
Organisation name
Postal address
State Postcode
Daytime phone( ) Fax( )
Email Ref
Name of the Financial Services Provider you have a dispute with
Have you made a complaint to the Financial Services Provider?
Yes
No
If so, when did you complain to the Financial Services Provider?
If your dispute concerns a decision made in relation to an insurance claim, the date recorded here should be
the first date you informed the insurer that you are not satisfied with its assessment of the claim, and that
you want the decision reviewed.
Since you made a complaint, have you received a written response from the Financial
Services Provider explaining its final position in relation to your complaint? (If so, please
attach a copy).
Yes
No
Financial
Services
Provider details
Representative
details
Day MonthYear
What sort of product or service is the dispute about (e.g. home loan, life or home
insurance policy, investment product)?
Please provide a reference number so that your Financial Services Provider can locate
the correct information (e.g. policy number, account number, complaint reference).
Please tell us what your dispute is about. If you have already written to us about your
dispute, please explain which issues have not been resolved. If you require more
space, please enclose additional pages with this form.
Reference No:
Dispute details
What do you think is a fair and reasonable resolution to the dispute? If you are seeking
payment of a sum of money please provide any relevant calculations of your claim(s).
Has the Financial Services Provider commenced legal proceedings against you in a
court?
Yes
No
Will you need an interpreter to deal with the Financial Ombudsman Service? If so, what
language?
Yes
No
Will you need any other special assistance (e.g. for a hearing or vision impairment)?
How did you hear about the Financial Ombudsman Service?
Another dispute resolution scheme
(e.g. Superannuation Complaints Tribunal)
Charity/church organisation
Community centre/consumer
representative
Event/trade fair/presentation
Financial Counsellor
Financial Planner
Financial Services Provider I have a
dispute with
Friend/Family/Colleague
Government Agency
(e. g. ACCC, ASIC, APRA)
Have always known about us
Industry Association (e.g. ABA,
FPA, IFSA)
Internet
Legal Aid/freelegal service
Media (e.g. Newspaper/magazine)
Member of Parliament
Phone directory
Solicitor/legal professional
Welfare/migrant service
Language
Please specify
Special needs
How you found
out about us
The Applicant(s) authorise the Financial Ombudsman Service(FOS), the Financial Services
Provider (FSP), any representative appointed by the Applicant(s) and any organisation
named in association with that representative, to exchange information about the
Applicant(s), including any relevant sensitive information, for the purpose of dealing with the
dispute. If multiple disputes are lodged by the Applicant(s) against different FSPs, the
Applicant(s) authorise relevant information to be exchanged between those FSPs by FOS.
If FOS determines that it is appropriate to refer the dispute to another dispute resolution
service or FSP, the Applicant(s) authorise FOS to do this.
For general information on how we deal with information provided to us, ourprivacy policy
Our dispute handling process is governed by our Terms of Reference. Our Terms of
______________________________________________ _____________________
Signature Applicant 1 Signature Applicant 2 Signature Representative
_______________________ _______________________ ______________________
Date Date Date
From time to time FOS contacts people to ask whether they would like to providefeedback
about FOS services. This will help us understand howwe can best improve as an
organisation. If you do not wish to be contacted by FOS to provide such feedback, please
tick the box below.
I/We do not wish to be contacted by FOS for the purposes of providing feedback
Please attach copies of all documents you have that relate to your dispute. If your
Financial Services Provider has written to you about your dispute, please ensure that you
provide a copy of its response.
Once complete please send this Dispute form together with all relevant details,
documents and correspondence to:
Financial Ombudsman Service
GPO Box 3
MELBOURNE VIC 3001
Email: xxx xxx
Office Use only
Reference number:
Supporting
documents
Survey
Authority
can be found at www.fos.org.au/privacy.
Reference can be found at www.fos.org.au/tor.
