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2. 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.
4. COMPLAINANT
6. Your Name*
7. Date *
9. Address1*
11. City*
12. State*
13. Zip*
15. Home Telephone Number
16. Cell Telephone Number*
18. Work Telephone Number
19. Are you a senior citizen?*

    1. Yes
    2. No
21. Email Address
23. SUSPECT
    List the name of the firm or individual the complaint is being made against. Identify the Salesman or Representative you dealt with.
25. 1. Name *
26. Telephone Number*
28. Address1
30. City
31. State
32. Zip
34. 2. Name
35. Telephone Number
37. Address1
39. City
40. State
41. Zip
43. How did you hear of the suspect (Newspaper,TV, etc.)
45. DETAILS
47. Date of Occurrence *
48. Amount of Loss*
50. Location of Occurrence (City and County)*
52. Was a contract signed?*

    1. Yes
    2. No
53. If yes, please attach a copy to this form
55. Did you complain to the company?*

    1. Yes
    2. No
56. Date(s) of complaint(s)
58. Do you have witnesses?*

    1. Yes
    2. No
59. Name(s), Address(es), and Telephone Number(s) of Witness(es)
61. Have you contacted an attorney?*

    1. Yes
    2. No
62. Name of attorney
64. Are any civil actions (lawsuits) pending?*

    1. Yes
    2. No
65. County and Case Number
67. Have you contacted any other agencies?*

    1. Yes
    2. No
68. Date of agency contact
70. Agency Name, Address, and Telephone Number
72. Are you willing to sign a complaint and testify in court?*

    1. Yes
    2. No
74. 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.
76. Attach additional remarks and copies of any documentation (contracts, letters, invoices, receipts)
77. Additional Documentation
79. 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

    1. I Agree
81. Date*
82. Electronic Signature*
Leave This Blank:


84. 1. Receive an email copy of this form.
85. Email address

    This field is not part of the form submission.

86. Submit Submit and Print

* indicates a required field