Form Complaint- 001 - Complaint Form - Arizona Department Of Financial Institutions Page 2

Download a blank fillable Form Complaint- 001 - Complaint Form - Arizona Department Of Financial Institutions in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Complaint- 001 - Complaint Form - Arizona Department Of Financial Institutions with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Arizona Department of Financial Institutions

Complaint Form

Telephone: (602) 771-2800

2910 N. 44

Street, #310, Phoenix, AZ 85018

Fax: (602) 381-1225

Description of Events

Place of Transaction

Date of Transaction

Witness to Transaction

Product or Service Involved

Yes

Was the product or services advertised? If possible, please provide a copy of the advertisement

Total Amount of Damages (list actual loss only)

Other Government Agency(ies) Contacted

Please describe the entire circumstances and events surrounding your complaint, in the order they occurred. When describing what happened please

include what, when, where, why, and how the events transpired and who was involved.

If necessary, please use additional sheets of paper, if you

need more space.

Please attach copies of all documents relevant to the complaint.

Preferred Resolution

What action by the company and/or person(s) would resolve this matter to your satisfaction? If necessary, please use additional sheets of paper, if you

need more space.

Yes

May we send a copy of your complaint to the company or person(s) you are complaining against?

If NO, the Department may be prevented from taking any action on your complaint

I declare, under penalty of perjury, that the facts and statements contained in the foregoing complaint,

including all attachments, are true and correct based on my personal knowledge.

Signature of Complainant

Date

Form: COMPLAINT- 001

Page 2

Revised: 3/10/2016