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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.

         

Department of Consumer Protection
112 East Post Road, 4th Floor
White Plains, New York 10601
PHONE: (914) 995-2155    FAX: (914) 995-3115
Visit Westchester County's Home Page at:
www.westchestergov.com