Consumer Protection Complaint Form
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1
2Consumer Protection Complaint Form
Tom Miller
Consumer Protection Division
Attorney General of Iowa
1305 East Walnut
Phone: 515-281-5926
Des Moines, Iowa 50319
Fax: 515-281-6771
Email:
consumer@iowa.gov
888-777-4590 (toll free, outside of Des Moines)
Instructions:
1. Please print or type. Answer all questions fully and correctly.
2. Please mail copies of all documents that may relate to your complaint claim (contracts, advertisements,
correspondence, proof of payment, etc.).
3. Return the information to the Consumer Protection Division (address above).
4. You may also file a complaint online. Be sure to include copies of all relevant documents.
5. PLEASE NOTE: Important “Open Records” information on page 2 of this form.
YOUR NAME AND ADDRESS:
NAME OF BUSINESS OR PERSON COMPLAINT IS AGAINST:
□ Mr.
□ Mrs.
□ Ms.
Age:
Name:
Name:
Address:
Address:
City, State, Zip Code:
City, State, Zip Code:
Primary Phone Number:
Primary Phone Number:
Email Address:
Email Address:
Website:
Please check appropriate box if you or your spouse are an active or former duty service member or U.S. military veteran:
□ I am an active duty service member
□ My spouse is an active duty service member
□ I am a U.S. Veteran
□ My spouse is a U.S. Veteran
For MOTOR VEHICLE COMPLAINTS, please list your Vehicle Identification Number (VIN):
Product or service involved:
Amount of purchase or contract:
Date of purchase or contract:
Amount paid:
Product new or used?
Form of payment (check, credit card, etc.):
Have you contacted the business or person? □ Yes
□ No
Have you contacted an attorney?
□ Yes
□ No
Name:
Date Contacted:
Name:
Date Contacted:
What do you think should be done to resolve your complaint fairly?
_
Page 1 of 2
Updated 4/15/2016
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Parent category: Legal