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Consumer Complaint Form
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The legal staff of the District Attorney's Office is not permitted to represent private citizens in court seeking the return of their money or other personal remedies.
COMPLAINANT
Your Name
*
Date
*
Address1
*
City
*
State
*
Zip
*
Home Telephone Number
Cell Telephone Number
*
Work Telephone Number
Are you a senior citizen?
*
Yes
No
Email Address
SUSPECT
List the name of the firm or individual the complaint is being made against. Identify the Salesman or Representative you dealt with.
1. Name
*
Telephone Number
*
Address1
City
State
Zip
2. Name
Telephone Number
Address1
City
State
Zip
How did you hear of the suspect (Newspaper,TV, etc.)
DETAILS
Date of Occurrence
*
Amount of Loss
*
Location of Occurrence (City and County)
*
Was a contract signed?
*
Yes
No
If yes, please attach a copy to this form
Did you complain to the company?
*
Yes
No
Date(s) of complaint(s)
Do you have witnesses?
*
Yes
No
Name(s), Address(es), and Telephone Number(s) of Witness(es)
Have you contacted an attorney?
*
Yes
No
Name of attorney
Are any civil actions (lawsuits) pending?
*
Yes
No
County and Case Number
Have you contacted any other agencies?
*
Yes
No
Date of agency contact
Agency Name, Address, and Telephone Number
Are you willing to sign a complaint and testify in court?
*
Yes
No
Briefly explain the facts upon which you base your complaint. Include first contact with the subject and anything the subject said/did/represented which later proved to be false.
Attach additional remarks and copies of any documentation (contracts, letters, invoices, receipts)
Additional Documentation
Electronic Signature Agreement
*
By checking the "I agree" box below, you agree and acknowledge that by signing in this electronic manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature
I Agree
Date
*
Electronic Signature
*
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Email address
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