Form Complaint- 001 - Complaint Form - Arizona Department Of Financial Institutions

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Arizona Department of Financial Institutions
Complaint Form
Telephone: (602) 771-2800
th
2910 N. 44
Street, #310, Phoenix, AZ 85018
Fax: (602) 381-1225
Your Information
First Name
Last Name
Mr.
Ms.
Address (line 1)
Address (line 2)
City
State
Zip Code
Primary Phone Number
Alternate Phone Number
Email
Company and/or Person(s) Complaint is against
Company Name
Person(s) you dealt with
Address (line 1)
Address (line 2)
City
State
Zip Code
Phone Number
Fax Number
Email
Website
Additional Information
Yes
No
1. Would you be willing to testify, under oath, regarding the matters set forth in this complaint?
Yes
No
2. Have you complained to the company and or person(s) involved?
If yes, to whom?
What was their response?
Yes
No
3. Did you sign any documents?
Yes
No
4. Have you contacted an attorney?
If YES,
please be aware the Department may be unable to act while there is pending litigation, but will still process your complaint.
Name of Firm
Attorney’s Name
Address (line 1)
Address (line 2)
City
State
Zip Code
Form: COMPLAINT- 001
Page 1
Revised: 3/10/2016

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