Consumer Complaint Form

Consumer Protection Office 800-282-0515 Fax 866-268-2279 30 E. Broad Street, 14th Floor Columbus, Ohio 43215 www.OhioAttorneyGeneral.gov Office Use Only: Complaint #: Consumer Complaint Form The Ohio Attorney General222s Consumer Protection Section provides a complaint resolution process to resolve disputes between consumers and businesses. If you have a complaint regarding a consumer transaction (a purchase or advertisement of a product or service used for the home or personal use), you may file a complaint with our office. By phone: Call 8 800-282-0515 You May File a Complaint One of Three Ways: Our help center associates will assist you in filing your complaint. Pre-Complaint Questions: PLEASE NOTE: Any information you submit with your complaint is considered public and may be released as part of a public records request. Remove Social Security numbers, credit card numbers, debit card numbers and other bank account numbers from any documents you submit with your complaint. 200 Have you contacted the company about your complaint? Yes No 200 Have you hired an attorney to represent you in this matter? Yes No If yes, provide: Attorney222s name: Attorney222s phone number: ( ) 200 Are you involved in a lawsuit regarding this issue? Yes No 200 Have you contacted any other agencies regarding this issue? Yes No If yes, please list the agencies: First name: MI: Last name: Suffix: Address: City: State: Zip Code: County: Country: Daytime phone: ( ) Alternate phone: ( ) E-mail address: Fax: ( ) Information about You (the Consumer): Subject of the Complaint (Business Information): Name of business you222re complaining about: Address: City: State: Zip Code: County: Country: Telephone: ( ) Toll-free: ( ) Fax: ( ) E-mail address: Web address: Name of business owner/salesperson: By mail: Complete this form in dark ink and mail to: Consumer Protection Section 30 E. Broad St., 14th floor Columbus, OH 43215-3400 Online : Visit w www.OhioAttorneyGeneral.gov On our Web site, you can file a complaint, sign up for our e-newsletter and learn about your consumer rights. American LegalNet, Inc. www.FormsWorkFlow.com D About the Transaction: How did the first contact with the company occur? Product/service involved: Date of purchase: / / (mm/dd/yyyy) Did you sign a contract? Yes No Are you making payments? Yes No Total cost of product/service: $ Method of payment: Amount paid so far: $ Disputed amount: $ Is the product/service under warranty? Yes No If yes, warranty company name: Describe the transaction and your complaint: E-mail Fax Home visit Infomercial Internet auction Internet banner/Web site Magazine/Newspaper Mail Radio Store visit Telephone call Television Word of mouth Other: Briefly describe what you would consider a reasonable resolution to your complaint: Motor Vehicle Complaints ONLY: Complete this section only if your complaint regards a motor vehicle : Make: Model: Purchase / Lease (circle one) Vehicle Identification Number (VIN227 not your license plate number ): Year of vehicle: New / Used (circle one) Under warranty / 223AS IS224 (circle one) Acknowledgment of Terms and Conditions: Mileage at purchase or lease: Current mileage: By checking this box I acknowledge that the information given above is true to the best of my knowledge and belief. I understand that any information I submit to the Ohio Attorney General222s Office is considered public information and may be released in a public records request. I understand a copy of this form and all documents relating to my complaint will be forwarded to the company that is the subject of my complaint. I understand that the Ohio Attorney General cannot serve as my private attorney. Date submitted : / / (mm/dd/yyyy) American LegalNet, Inc. www.FormsWorkFlow.com Consumer Protection Office 800-282-0515 Fax 866-268-2279 30 E. Broad Street, 14th Floor Columbus, Ohio 43215 www.OhioAttorneyGeneral.gov Office Use Only: Complaint #: Consumer Complaint Form, Part 2 When you file a consumer complaint with the Ohio Attorney General222s Office, you also must submit copies of documents related to your complaint, such as contracts and receipts. Submitting these documents helps ensure that you will get the best possible results from our complaint resolution process. Failure to provide required documentation may prevent or delay our ability to help you. Please send this form and copies of any documents related to your complaint to the Attorney General222s Office: Consumer Protection Section, 30 E. Broad St., 14th floor, Columbus, OH 43215-3400 DO NOT SEND ORIGINALS. Any documents sent to our office will be scanned electronically and then destroyed. PLEASE NOTE: Any information you submit with your complaint is considered public and may be released as part of a public records request. Remove Social Security numbers, credit card numbers, debit card numbers and other bank account numbers from any documents you submit with your complaint. Documents to Submit with Your Complaint: Check below to indicate which documents/items you are submitting with your complaint (check all that apply): Contract / Purchase Agreement HUD 1 Settlement Statement (Residential Mortgage Transactions Only) Warranty / Service Agreement Invoice / Billing Statement Debt Collection Account Number* (Debt Collection Complaints Only): Payment Record / Receipt Advertisement Other: Estimate / Proposal Loan Application *DO NOT SUBMIT YOUR BANK ACCOUNT NUMBER OR SOCIAL SECURITY NUMBER. Additional Information about You: To help our office better serve Ohio consumers, please check any/all categories that apply to you (optional): Active service member or immediate family of active service member Disaster victim Non-English speaking Person with disability Over the age of 65 American LegalNet, Inc. www.FormsWorkFlow.com