Consumer Complaint Form - Georgia Page 2
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3PLEASE TYPE OR PRINT LEGIBLY
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CONSUMER'S CONTACT INFORMATION:
Mr./
First
Middle
Last
Mrs.
Name:
Name:
Name:
Mailing
Address:
9-Digit
City:
State:
Zip Code:
_
_
Home Phone:
Email:
Business
_
_
_
_
Phone:
Fax:
We can accept complaints from third parties on behalf of consumers only in limited circumstances. If you are filing on
behalf of another person, please give your contact information.
Mr./
First
Middle
Last
Mrs.
Name:
Name:
Name:
Mailing
Address:
9-Digit
City:
State:
Zip Code:
_
_
Phone:
Email:
Relationship
to Consumer:
════════════════════════════════════════════════════════════════
INFORMATION ABOUT THE BUSINESS:
Name:
Address:
9-Digit
City:
State:
Zip Code:
_
_
Web
Phone:
Address:
Dates you complained
to the business:
Name(s) and title(s) of individuals at business with whom you dealt:
____________________________________________________________
____________________________________________________________
____________________________________________________________
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