Form Fed-402 - Below Cost Selling Of Motor Fuel Complaint

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Complaint Form
Below Cost Selling of Motor Fuel
Alleged Violator
Name of Retailer
Actual Street Address (No cross streets will be accepted)
City
County
Product and grade of the motor fuel you suspect is being sold below cost.
being sold at $
/gallon
being sold at $
/gallon
being sold at $
/gallon
Date and time of day price posting was observed
Complainant
Complainant’s Motor Fuel Inspection registration number
Complainant’s Full Name
(List your individual name, not a corporate or trade name.) PLEASE PRINT CLEARLY
Address
City
Zip
County
Complainant’s Phone #
Fax #
E-Mail Address
Results to me by
U.S. Mail
Fax
E-Mail
Signed
Date
COM/FED-402 (Rev. 05/09)
Page 1

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