Consumer Complaint Form - Georgia Page 3
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SPECIFICS OF YOUR DISPUTE OR COMPLAINT:
Product/
Service:
Date of
Occurrence:
Total Cost:
Amount Paid to Date:
Did you sign a contract?
O Yes
O No
Are you still making payments?
O Yes
O No
Payment Method:
O Cash
O Check
O Credit Card
O Debit Card
O Other
Did you contact the company as the result of an advertisement?
O Yes
O No
What type of ad?
O TV
O Radio
O Newspaper/Magazine
O Mail
O Internet
O Other
Please describe your complaint briefly but with enough details to make the situation clear. Describe any claims you feel are deceptive,
misleading or false. If needed, attach additional pages.
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
What form of relief have you requested, or what would you consider a satisfactory solution to the situation? (Refund, exchange, repair,
etc.)
____________________________________________________________
____________________________________________________________
Have you contacted another government agency?
O Yes
O No
If yes, which agency and what was the result:
____________________________________________________________
____________________________________________________________
Have you hired a private attorney?
O Yes
O No
Attorney’s name/phone number:
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Thank you for providing this information to the Governor's Office of Consumer Protection. You will hear from us after our review of the
matter.
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