* indicates a mandatory field

Your Information

Prefix:	Mr. Ms. Mrs.	* First Name:
Middle Initial:		* Last Name:
* Mailing Address:
* City:
* State:		* Zip Code:
Country, if not US:
Day Phone Number (including area code):
Evening Phone Number (including area code):
Cell Phone Number (including area code):
Fax Number (including area code):
County of Residence:		Email Address:
I am a military service member, veteran, or military spouse:		No Yes

Information About Company Against Which You Are Complaining

* Full name of company:
Address:
City:
State:		Zip Code:
Country, if not US:
Company’s internet address (URL):
* Telephone number, including area code:
Fax number, including area code:

Complaint Information (complete any blocks which apply to your complaint)

Product, item, or service involved:

Date of purchase, service, contract:		Date and timeNow
Manufacturer or brand:
Model:
Account number:			Do not submit credit card or bank account numbers through this form. If you need to provide that information as part of your complaint, please mail it to us instead.
Serial number:
Did you sign a contract or a lease?:	Yes No
Start Date:	Date and timeNow	End Date:	Date and timeNow
Total amount paid:		Amount in dispute:
How was payment made:	Cash Check Credit card Debit card Money order Wire transfer Finance agreement Other
Did you buy an extended service contract?:	No Yes
If yes, name of company responsible for extended service contract or warranty:

Information About the Transaction

How was initial contact made between you and the:	Other Person came to my home I went to company’s place of business I received a telephone call from business I telephoned the business I received information in the mail I responded to radio/television ad I responded to printed advertisement I responded to a Website or e-mail solicitation I received a fax solicitation I attended a trade show or convention
Where did the transaction take place?:	Other At my home At company’s place of business By mail Over the phone Via computer (website or e-mail) Trade show or hotel

Details of Complaint

* Details: Limit of 2500 characters

Resolution Attempts You Have Made

Have you contacted the company with your complaint?:	No Yes
If yes, name of person most recently contacted:
His/her phone number, incl. area code:
Results:
* What resolution would you consider fair?:
Do you have an attorney in this case?:	No Yes
If yes, name of your attorney:
Attorney’s number, incl. area code:
Has your complaint been heard or is it scheduled to be heard in court?:	No Yes
If yes, where and when?:
If already heard, what was the result?:
Will you be submitting documentation by mail or fax?:	Select One No Yes
Please attach up to four supporting documents in pdf, doc, docx or txt format.  You may also mail supporting documents to us.
Attachment 1:	Upload:Upload file
Attachment 2:	Upload:Upload file
Attachment 3:	Upload:Upload file
Attachment 4:	Upload:Upload file

PLEASE NOTE: The maximum size of your submission is 15 Mb including the form and all attachments.  If you receive an error that says "maximum request exceeded", you need to reduce the size of your attachments or contact Consumer Protection directly to provide the attachments.


  After you’ve completed the form and printed copies, please hit submit to send your complaint to the Consumer Protection Division.