Consumer Complaint Form

Add Portal Case Consumer

a1207231569584600
Portal Submission 
*
Email Address is required. This email address will be used to send a confirmation email after Portal Submission is complete.
COMPLAINT FORM
 
Some information on this form may not apply to your complaint. Please complete the fields that are applicable to your situation.
 
Please provide as much information as possible about the matter.
 
* Denotes required fields
 
CONSUMER INFORMATION:
*
*
*
*
*
*
*
 
COMPANY INFORMATION: (Business filing complaint against)
*
*
*
*
*
*
Name of Person you dealt with
Product or Service    Manufacturer 
Make Model (year/type/number)
Serial Number Date of Purchase 
Place of Purchase or service  Amount Paid
Amount Financed   Date of your last contact with business
 
With whom did you speak Title

 What was the response?

INCLUDE COPIES OF ALL CORRESPONDENCE WITH THIS COMPLAINT FORM

What other agencies have you contacted about this complaint?

Complete if Complaint is a Suspected Scam

How did you pay?  How much did you pay?

How were you contacted? (if via phone – provide the phone number, date, and time of the call)

When were you first contacted?

Summary of Complaint

Briefly describe your complaint. Include specific dates. Please remember a copy of this form may be provided to the business. 

*

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.

____________________________________________________________________________________________________________

 

AFFIDAVIT

By signing this complaint, I consent for my name to be used by the Attorney General's Office in any subsequent legal action that is deemed necessary.

I hereby swear or affirm that the above statements are true and correct to the best of my knowledge.

  

*
Signature   Date
Allowed File Types: .pdf, .doc, .docx, .rtf, .zip, .tiff, .bmp, .jpeg, .png, .xml, .csv, .xlsx

files

 
CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

Image CAPTCHA

Enter the characters shown in the image.