Complaint Form Section 1. Your Information Name: Address: City: State: ZIP Code: Email Address: Phone Number: _____________________________________________________________________________ Section 2. Name of Company or Individual about which or whom you are complaining Company/Business Name: Address: City: State: ZIP Code: Phone Number: Website: _____________________________________________________________________________ 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: How was payment made: CashCheckCredit cardMoney orderOther Did you receive a receipt for your purchase? YesNo How was the transaction initiated? Business contacted meFlyerRadio/televisionSelf initiatedOther _____________________________________________________________________________ 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? Have you contacted any other agency or individual regarding this complaint? What resolution would you consider mutually fair? _____________________________________________________________________________ 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. _____________________________________________________________________________ Δ {{#message}}{{{message}}}{{/message}}{{^message}}Your submission failed. The server responded with {{status_text}} (code {{status_code}}). Please contact the developer of this form processor to improve this message. Learn More{{/message}}{{#message}}{{{message}}}{{/message}}{{^message}}It appears your submission was successful. Even though the server responded OK, it is possible the submission was not processed. Please contact the developer of this form processor to improve this message. Learn More{{/message}}Submitting…