Consumer Complaint Form
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1
2CTS NO._____________________
REGIONAL NO. _______________
CATEG. CODE: _______________
Consumer Complaint Form
1.
Please be sure to complain to the company or individual before filing.
2.
Please type or print clearly in dark ink.
3.
Incomplete or unclear forms will be returned to you.
4.
Make sure you enclose copies of important papers concerning your transaction.
Consumer
Name:_________________________________________Senior Citizen?
Yes
No
Day Telephone: _________________________________Night Telephone: ______________________________________________
Address: _______________________________________City: _____________________State: ____________ Zip:______________
Complaint
Name of Seller or Provider of Services: ___________________________________________________________________________
Address: _______________________________________City: _____________________State: ____________ Zip:______________
Telephone: _____________________________________
Name of Other Seller or Provider of Services: ______________________________________________________________________
Address: _______________________________________City: _____________________State: ____________ Zip:______________
Telephone: _____________________________________
Date of Transaction: ______________________________Cost of Product:___________________How Paid: ___________________
Did you sign a contract?
Yes
No
Where? _________________________Date: _______________________
Was product or service advertised?
Yes
No
Where? _________________________Date: _______________________
Type of Complaint (e.g. car, mail order, etc.) please provide details on reverse side:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Have you complained to the company or the individual?
Yes
No
Date: _______________________
How?
By Phone
By Mail
In Person
Other _______________________________________________________________
Person Contacted: _______________________________Job Title: ____________________________________________________
Nature of Response: _____________________________________________________________Date: _______________________
Has matter been submitted to another agency or attorney?
Yes
No
If yes, give name and address:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Is court action pending?
Yes
No
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Parent category: Legal