Complaint Form Consumer
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1
2State of Maine
WILLIAM J. SCHNEIDER,
Office of Attorney General
Attorney General
Consumer Protection Division
Complaint #
Consumer Mediation Service
6 State House Station
Mediator
Augusta, ME 04333-0006
PDF
COMPLAINT FORM
CONSUMER
Please answer the questions below as completely as possible and include copies of your bills, contracts, estimates, receipts,
warranty, advertisements, etc. Do not send originals. Please print neatly or type. Please do not use staples.
Name Of Business Complaint Is To Be Filed Against
Name of Consumer
Name of
Your
Business:________________________________
Name:_____________________________________
Address:_________________________________
Address:___________________________________
City: ___________ State: _____ Zip: _________
City:______________State:______ Zip: __________
Tel:____________________________________
Tel: Work _________Home ___________________
Fax:____________________________________
Cell:___________________Fax:____________________
___________________________________
______________________________________
Email:
Email:
_______
__
Specific details about the transaction:
Name of
Manufacturer:____________________________
Did you sign a contract?
Yes: ____ No:____
Did you receive a warranty?
No:___
Yes: ____
Address:_________________________________
Did you buy an extended warranty?
Yes: ____ No:____
Did you pay by credit card?
Yes: ____ No:____
City: ____________State: _____ Zip: _________
Have you contacted your credit card company to
Tel:____________________________________
dispute
dispute your bill and request a credit to your account?
Fax:____________________________________
Yes: ____ No:____
Email:__________________________________
________
Date of Transaction:__________________ Price
Amount of money paid
:$________________
? $___________
Name of person you dealt with:
______________________________________________________________________________________
Was the service or product advertised? Yes __ No __ If yes, was the advertisement accurate? Yes ___ No ___
What is the product or service you are complaining about? ________________________________________________
_______________________________________________________________________________________________
Have you submitted this matter to another agency or lawyer?
Yes ____
No ____
Agency’s or lawyer’s name and phone:
____________________________________________________________________________________________
Have you sued the company or has the company sued you?
Yes ____
No ____
May we send a copy of this complaint to the business?
Yes ____
No ____
If you check “no” we will not be able to mediate your complaint.
However, we will keep your complaint in our files.
PLEASE COMPLETE THE OTHER SIDE
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Parent category: Legal