Consumer Complaint Form
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ONSUMER
OMPLAINT
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ENERAL
OMPLAINT
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FFICE OF THE
TTORNEY
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ONSUMER
ROTECTION
IVISION
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9/07
EVISED
STATEWIDE TOLL FREE 1-800-551-4636
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ONSUMER
NFORMATION
Name ________________________________________________________________________________________________________________________________
Please Print or Type
Last
First
Middle Initial
Address:_______________________________________________________________________________________________________________________________
City:__________________________________________________________________________State______________Zip___________________________________
Phone: Day: (______) ___________________ Evening: (______) ______________________ E-mail address: ___________________________________________
In order to process your complaint, the Attorney General’s Office will send a copy of your complaint to the complained of business. Do you want the
Yes
No
Attorney General’s Office to send this business a copy of your complaint?
I understand that if I answer No, the Attorney General’s Office will not process this complaint. Additionally, if I answer Yes, I understand my complaint
and any related documents I have submitted will become “public record.” Under state law, public records are subject to public records disclosure
requests. Under some circumstances, my complaint and related documents may therefore be seen by other people.
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USINESS
NFORMATION
Name of business you are complaining about: _________________________________________________________________________________________________
Address:_______________________________________________________________________________________________________________________________
City:________________________________________________________ State:_____________________________ Zip:____________________________________
Phone: (______)______________ Fax: (______) ______________ Toll-free number: _________________ E-mail address: ___________________________________
Name of Owner or Manager (if known):______________________________________________________________________________________________________
Names and addresses of any other businesses involved in your complaint:___________________________________________________________________________
______________________________________________________________________________________________________________________________________
Item or service purchased:_________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
Cost of item or service: __________ Did you sign a contract?________ Date of transaction: ____/____/____
Salesperson’s name:__________________________________________________________________________
Was an advertisement involved? _______ Date and source of advertisement:_________________________________________________________________________
(Please send a copy of the advertisement if it is available.)
A
Y
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BOUT
OUR
OMPLAINT
Yes
No
Have you complained to the business?
If YES, to whom: (and their position)____________________________________________________________
What response did you receive? _____________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Yes
No
Have you filed a complaint about this business with the Attorney General’s Office before?
If Yes, list the file number ___________________________
Yes
No
Have you contacted a private attorney?
If YES, identify the name and address of the attorney:_______________________________________________
_______________________________________________________________________________________________________________________________________
Yes
No
Is there a court or other legal proceeding pending?
If YES, please explain:_______________________________________________________________
_______________________________________________________________________________________________________________________________________
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