Consumer Complaint Form - Office Of The Indiana Attorney General Page 2
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210. HAVE YOU COMPLAINED TO THE BUSINESS? (Check box when applicable)
Yes No
When? _______________________________________ Action taken? __________________________________________
__________________________________________
11. WITH WHAT OTHER AGENCY HAVE YOU FILED THIS COMPLAINT?
When? _______________________________________ Action taken? __________________________________________
12. HAVE YOU CONTACTED A PRIVATE ATTORNEY?
Yes No
13. HAVE YOU STARTED A COURT ACTION? IF YES, PLEASE ATTACH A COPY OF ALL COURT PAPERS.
Yes No
14. HAVE YOU BEEN SUED OVER THIS ISSUE? IF YES, PLEASE ATTACH A COPY OF ALL COURT PAPERS.
Yes No
15. DOLLAR AMOUNT ASSOCIATED WITH YOUR LOSS, IF ANY. $__________
16. PLEASE DESCRIBE YOUR COMPLAINT IN DETAIL (ATTACH ADDITIONAL PAGES IF NECESSARY)
Please attach a copy of all papers involved (order blank, warranty, credit card receipt and statement, invoice, contract or written agreement, advertisement, cancelled
check, correspondence and all other related documents). Please print clearly or type. DO NOT INCLUDE YOUR SOCIAL SECURITY NUMBER.
17. HOW WOULD YOU LIKE YOUR COMPLAINT RESOLVED?
18. CONSENT AND VERIFICATION
I affirm, under the penalties for perjury, that the foregoing representations, and those in all attachments, are true. The information I
have provided in this complaint form is based upon my personal knowledge. I consent to the Consumer Protection Division obtaining or
releasing any information in furtherance of the disposition of this complaint. I understand that I should not include my Social Security
Number in any information submitted to the Consumer Protection Division. If I do provide my Social Security Number, I expressly consent
to the disclosure of my Social Security Number in accordance with Indiana Code § 4-1-10-5(2).
Your Signature
Date
WHAT WILL HAPPEN NOW? WHAT ELSE SHOULD YOU DO?
MAIL COMPLETED FORMS TO:
Attorney General Greg Zoeller
The Consumer Protection Division will send a copy of your complaint to the
Consumer Protection Division
respondent firm or licensed professional. This office cannot disclose your complaint
Government Center South, 5
floor
th
against a licensed professional to the public unless this office files a disciplinary
302 West Washington Street
action against the licensed professional. This office represents the State of Indiana
Indianapolis, IN 46204
and is limited in the remedies it can pursue. You may be entitled to compensation
PH: 317-232-6330 • FAX: 317-233-4393
or other rights that we cannot pursue for you. In addition to filing this complaint, you
may want to consider contacting a private attorney or your local small claims court.
Rev. 01-09
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