Taxpayer Protection Bureau - Complaint Form Page 2
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2PLEASE BRIEFLY DESCRIBE YOUR COMPLAINT BELOW:
(Please attach additional documentation if necessary)
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READ THE FOLLOWING BEFORE SIGNING BELOW:
In filing this complaint, I understand that the Attorney General is not my private attorney, but
represents the public in enforcing laws designed to protect the public from misleading or
unlawful business practices. I also understand that if I have any questions concerning my legal
rights or responsibilities, I should contact a private attorney. I have no objection to the contents
of this complaint being forwarded to the business or person the complaint is directed against. The
above complaint is true and accurate to the best of my knowledge. I also understand that any
false statements made in this complaint are punishable as a Class A Misdemeanor under Section
175.30 and/or Section 210.45 of the Penal Law.
Signature: ____________________________________ Date: ____________________
PLEASE NOTE:
Your submission of this form does not create any rights for you to share in a recovery that the
government might obtain. If you wish to learn more about New York’s whistleblower law (the
New York False Claims Act) or your own rights, please consult a lawyer or refer to our website
at:
for more information.
PLEASE RETURN THIS FORM TO:
New York State Office of the Attorney General
Taxpayer Protection Bureau
120 Broadway, 22nd Floor
New York, NY 10271-0007
(212) 416-6012
TB001 - (rev. 6/16)
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