COMPLAINT FORM
Check Action Desired
CONSUMER INFORMATION
LastName FirstName MiddleName
Address Line 1 Address Line 2
City State Zip
Home Phone
- -
Business Phone
- -
Extn:  
Fax Number
- -
Email to get confirmation Email Confirm  
COMPANY INFORMATION
Company Name Business Phone
- -
Company Address Line 1 Line 2
City State Zip
CONTACT PERSON (OWNER/MANAGER) INFORMATION
LastName FirstName MiddleName
Address Line 1 Address Line 2
City State Zip
Home Phone
- -
Business Phone
- -
 
E-Mail Address
ADDITIONAL INFORMATION
Name of person you dealt with
Product or Service Manufacturer
Make Model
Serial Number Date of Purchase (MM/DD/YYYY)
Place of Purchase or service Amount Paid
Amount Financed Date of your last contact with business (MM/DD/YYYY)
With whom did you speak? His/Her title?
What other agencies you have contacted about this complaint?
SUMMARY OF COMPLAINT
(Briefly describe your complaint. Include specific dates. Please remember a copy of this form will be given to the business.)
Complaint
What was the response?

Attach COPIES of any relevant documents such as letters, bills of sale, contracts, warranties, advertisements, work, orders, bills etc. DO NOT SEND ORIGINALS TO THIS OFFICE.
 File Name
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