Consumer Complaint Form (Page 3 of 3) in pdf

Consumer Protection

Office 800-282-0515

Fax 866-268-2279

30 E. Broad Street, 14

Floor

Columbus, Ohio 43215

Office Use Only:

Consumer Complaint Form, Part 2

Complaint #:

When you file a consumer complaint with the Ohio Attorney General’s Office, you also must submit copies of documents

related to your complaint, such as contracts and receipts. Submitting these documents helps ensure that you will get the

best possible results from our complaint resolution process. Failure to provide required documentation may prevent or

delay our ability to help you.

Please send this form and copies of any documents related to your complaint to the Attorney General’s Office:

Consumer Protection Section, 30 E. Broad St., 14th floor, Columbus, OH 43215-3400

DO NOT SEND ORIGINALS. Any documents sent to our office will be scanned electronically and then destroyed.

PLEASE NOTE: Any information you submit with your complaint is considered public and may be released as

part of a public records request. Remove Social Security numbers, credit card numbers, debit card numbers

and other bank account numbers from any documents you submit with your complaint.

Documents to Submit with Your Complaint:

Check below to indicate which documents/items you are submitting with your complaint (check all that apply):

HUD 1 Settlement Statement (Residential Mortgage

Contract / Purchase Agreement

Transactions Only)

Warranty / Service Agreement

Debt Collection Account Number* (Debt Collection

Invoice / Billing Statement

Complaints Only):

Payment Record / Receipt

Other:

Estimate / Proposal

Loan Application

*DO NOT SUBMIT YOUR BANK ACCOUNT NUMBER OR

SOCIAL SECURITY NUMBER.

Additional Information about You:

To help our office better serve Ohio consumers, please check any/all categories that apply to you (optional):

Active service member or immediate family of active service member

Federal Poverty Guidelines (2012)

Number of people

250% of federal

Disaster victim

in your family:

poverty guideline:

Income below 250% of federal poverty guideline (see chart)

1…………

$27,925

2…………

$37,825

Non-English speaking

3…………

$47,725

4…………

$57,625

5…………

$67,525

Person with disability

6…………

$77,425

7…………

$87,325

Over the age of 65

8…………

$97,225

Consumer Complaint Form Page 3

Related Articles

Related forms

Related Categories