Home Improvement Contractor Page 2
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1
2Tell Us about Your Complaint
Reason for your complaint
_________________________________________________________________________________________
*Product/Service involved
*Date of transaction
_________________________________________________
______________________
Was this an Internet order or purchase?
*Do you have a written contract?
*Cost of product/service_____________*Amount paid to date____________
How did you pay?
If you paid by credit card, have you contacted your credit card company?
*Is this matter pending in court? If yes, what court?___________________________________________________________
What action are you seeking from DCA to resolve this complaint? Check ONE box only.
Note: If you checked one of the boxes above, you must check the box “I want help with my complaint” on front.
Briefly describe your complaint. Use additional pages as needed.
Provide Your Information
*Name_______________________________________________________________________________________________
(First and Last)
*Home Address________________________________________________________________________________________
(Include Apartment #)
*City, State, ZIP_________________________________________________ Country _______________________________
*Contact number__________________________________________
Are you currently serving on active duty in the U.S. Armed Forces?
Are you a veteran of the U.S. Armed Forces?
Would you like to receive electronic communications from DCA?
_________________________________________________________________________
If Yes, provide E-mail
*Print Name________________________________*Signature________________________________*Date____________
Provide Information about the Business
*Business Name_______________________________________________________________________________________
*Address_______________________________________________________*Daytime Phone ________________________
*City, State, ZIP
*Fax
____________________________________________________________
__________________________________
*Type of Business_____________________________________
(For home improvement contractor complaints, answer the questions on front.)
E-mail_______________________________________*License #________________________________________________
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Parent category: Legal