* indicates a mandatory field

Your Information

Prefix:	Mr. Ms. Mrs.	* First Name:
MI:		* Last Name:
* Mailing Address:
* City:
* State:		* Zip Code:
County of residence:		Country, if not US:
Day phone number, including area code:
Evening phone number, including area code:
Fax number, including area code:
Cell phone, including area code:
E-mail 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:
Mailing Address:
City:		State:
Zip code:		Country, if not US:
* Telephone number, including area code:
Fax number, including area code:

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

Year:		Make:
Model:		VIN#:
Mileage:
Is your complaint about:		New car sales practices Used car sales practices Warranty Repossession Towing Manufacturing Defect Repairs Financing or leasing Damage disclosure Title issues

Date of purchase:
Date of repair:
How did you buy your vehicle?:		New Used As Is
Where financed (if relevant). Include address.:
Did you sign a lease?:		Yes No
Starting date:
Expiration date:
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?:		Yes No
Name of company responsible for extended service contract or warranty:
If repairs, indicate type of repairs or services performed (Air conditioner, brakes, oil change, transmission, etc.):
Before any work was performed, did you receive an estimate?:		Yes No
Did you authorize any changes to the original estimate?:		Yes No
If yes, provide details:
Were the completed repairs different from what you had authorized?:		Yes No
If yes, provide details:

Information About the Transaction

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

Details of Complaint

* Provide details of your complaint: Limit of 2500 characters

Resolution Attempts You Have Made

Have you contacted the company with your complaint?:	Yes No
Name of person most recently contacted:
His/her phone number, incl. area code:
Results:
* What result would you consider fair?:
Do you have an attorney in this case?:	Yes No
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? 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.