Compliance Enforcement Complaint Form
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3Occupational and Business Licensing
555 Wright Way
Carson City, Nevada 89711
(775) 684 - 4690
COMPLAINT
VOLUNTARY STATEMENT
Case No
File Date
. _______________
______________
I wish to file a complaint against the business or individual named below. I understand that the Department of Motor Vehicles DOES
NOT represent private citizens seeking return of monies or other personal remedies as a result of contractual disputes or civil actions.
Person Filing Complaint:
Name _______________________________________________________Day Time Phone ______________________
Address _____________________________________________________Home Phone _________________________
City _______________________________________________________________State ____________Zip __________
Business or Individual Complaint Filed Against:
Business License No _____________________
(If applicable)
Business Name ____________________________________________Phone __________________________________
Address__________________________________________________________________________________________
Street
City
State
Zip code
Representative’s Name _____________________________________________________________________________
Vehicle Involved:
(If applicable)
VIN |____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
Year _______________Make _______________________Model ____________________Color ___________________
Other complaint not involving a motor vehicle sale or repair.
Explain Complaint: (Please attach copies of any documents you have to support your complaint.)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
I, _______________________________________________ freely and voluntarily give this affidavit to the State of Nevada,
Department of Motor Vehicles. I further certify and affirm that all information is true and correct to the best of my knowledge and that I
will testify to these facts if requested to do so in any action brought against the business or individual named above.
___________________________________________________
________________________________
Signature of Complainant
Date
___________________________________________________
________________________________
Signature of Notary or Authorized DMV Representative
Date
Forward the completed form to your local Compliance Enforcement Division office as listed below.
SOUTHERN NEVADA
NORTHERN NEVADA
Department of Motor Vehicles
Department of Motor Vehicles
Compliance Enforcement Division
Compliance Enforcement Division
8250 West Flamingo Road
305 Galletti Way
Las Vegas, NV 89147
Reno, NV 89512
CED20 (5/2010)
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