Department of Consumer Protection Complaint Form

Consumer Complaint Form
Please complete as much information as possible and click the "Submit Complaint" button at the bottom of this form. * Indicates a required field

First Name:*

Middle Initial:

Last Name:*

Street Address:*

City:*

State:*

Postal Zip Code:*

Daytime Telephone:*

Please include the area code.
If you do not have a phone, please indicate, "no phone"

Email Address:

Please complete the following information about the company you are submitting a complaint against:

Company Name:*

Street Address:

Additional Address:

City:*

State:*

Postal Zip Code:

Telephone Number:

Please include the area code:

Internet Address:

Internet Email:

Product or Service in Dispute:*

Is the service or product for a Home Improvement?
Click in the box if your answer is "Yes."

Date of Transaction:*

Example: 1/2/00

Name of Company Representative

Title of Representative

Example: Sales Associate

Total cost of product or service:*

Example: $1,078.76

Amount you paid:

Example: $545.76

Date you contacted the company concerning your complaint?

Example: 1/2/00

Name of person contacted:

Describe the nature of your complaint:*
(max. 3000 chars.)

What
resolution
are you
seeking?*

When you submit this complaint, you are certifying that the information you have given is true and complete to the best of your knowledge.