Complaint Form

Section 1. Your Information

Name:

Address:

City:

State:

_____________________________________________________________________________

Section 2. Name of Company or Individual about which or whom you are complaining

Company/Business Name:

Address:

City:

State:

_____________________________________________________________________________

Section 3. Complaint Information

Type of product, item, or service involved:

Date of purchase/service/contract:

Did you sign a contract or lease?
YesNo

If Yes, indicate
---Start date:
---Expiration date:

Total amount paid:

_____________________________________________________________________________

Section 4. Detailed description of Complaint

_____________________________________________________________________________

Section 5. Resolution attempts you have made

Have you contacted the company or individual?
YesNo

If Yes, name of the person most recently contacted:

Phone number:

Email address:

Results of your resolution attempt:

If necessary, would you be willing to testify in court?

_____________________________________________________________________________

Section 6. Disclaimers and Affidavits

By clicking "SUBMIT" below, you:

• authorize the Office of the Attorney General and any other local, state or federal agencies with which we may work on this matter, to evaluate your complaint, to contact you, and to take whatever lawful actions are deemed appropriate with regard to your complaint.

• certify that the statements made herein or on any attached documentation are true and complete to the best of your knowledge, information and belief.

• acknowledge that this complaint will become part of the Office of the Attorney General’s records and you authorize the release of information and documentation relative to this complaint.

_____________________________________________________________________________