Consumer Complaint Form - Office Of The Indiana Attorney General
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1
2CONSUMER COMPLAINT FORM
Office of the Indiana Attorney General
To prevent delay, please be sure to complete both sides of this form in full. Please print clearly or type. DO NOT include your Social
Security Number on this form or in any accompanying documents.
1. YOUR INFORMATION
2. WHO IS YOUR COMPLAINT AGAINST?
Name/Firm ______________________________________
Mr. Mrs. Miss Ms. Dr.
Name _ _________________________________________
_ _____________________________________
Address ________________________________________
Address ________________________________________
City ___________________________ State __________
________________________________________
ZIP ______________________ County _______________
City ___________________________ State __________
Age
18-24 25-34 35-44 45-54 55-64 65+
ZIP ______________________ County _______________
( )
( )
Phone ______________________________________ Day
Phone __________________________________________
( )
___________________________________ Evening
E-mail __________________________________________
E-mail __________________________________________
Person you dealt with ______________________________
3. WHEN DID TRANSACTION/INCIDENT OCCUR?
Date
Time
AM
PM
4. WHERE DID THE TRANSACTION/INCIDENT YOU ARE COMPLAINING ABOUT TAKE PLACE? (Check box when applicable)
At the firm’s place of business
By Mail
My home
By Internet/e-mail
Away from the firm’s place of business (work, convention, etc.) By telephone
Other __________________________________________
5. WHAT WAS THE VERY FIRST CONTACT BETWEEN YOU AND THE FIRM?
I telephoned the firm
I went to the firm’s place of business
I responded to a TV/radio ad
I received a telephone call from the firm
A person came to my home
I responded to an offer on the Internet
I received information by e-mail
I responded to a printed advertisement
I received information in the mail
Other ______________________________________
6. DO YOU CONSENT TO DISCLOSING THE FOLLOWING TO THE PUBLIC?
7. WHAT WAS THE TRANSACTION FOR?
The nature and status of your complaint and the name of the firm?
Yes
No
My business
Your name?
Yes No
My family/household
Your phone number?
Yes No
My farm
8. HOW DID YOU PAY?
Cash Credit Card Medicaid
Private Insurance
Check
Installment Loan
Medicare
Other ___________________________
9. DID YOU SIGN ANY WRITTEN AGREEMENT? IF YES, PLEASE ATTACH A COPY OF THE AGREEMENT.
Yes No
For Office Use Only:
Ind
Prac
OA:
Inv.
Sec
File #
PL
MO
NL
NJ
-CP-
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