9. DID YOU SIGN ANY WRITTEN AGREEMENT? IF YES, PLEASE ATTACH A COPY OF THE AGREEMENT. Yes No
I telephoned the firm I went to the firm’s place of business
I responded to a TV/radio ad I received a telephone call from the firm
A person came to my home I responded to an offer on the Internet
I received information by e-mail I responded to a printed advertisement
I received information in the mail Other ______________________________________
To prevent delay, please be sure to complete
both sides of this form in full. Please print clearly or type. DO NOT include your Social
Security Number on this form or in any accompanying documents.
4. WHERE DID THE TRANSACTION/INCIDENT YOU ARE COMPLAINING ABOUT TAKE PLACE? (Check box when applicable)
At the firm’s place of business By Mail
My home By Internet/e-mail
Away from the firm’s place of business (work, convention, etc.) By telephone
Other __________________________________________
5. WHAT WAS THE VERY FIRST CONTACT BETWEEN YOU AND THE FIRM?
7. WHAT WAS THE TRANSACTION FOR?
My business
My family/household
My farm
6. DO YOU CONSENT TO DISCLOSING THE FOLLOWING TO THE PUBLIC?
The nature and status of your complaint and the name of the firm?
Yes No
Your name? Yes No
Your phone number? Yes No
8. HOW DID YOU PAY?
Cash Credit Card Medicaid Private Insurance
Check
Installment Loan Medicare Other ___________________________
Ind Prac OA: Inv. Sec File #
PL
MO NL NJ
-CP-
For Office Use Only:
3. WHEN DID TRANSACTION/INCIDENT OCCUR? Date Time AM PM
CONSUMER COMPLAINT FORM
Office of the Indiana Attorney General
1. YOUR INFORMATION
Mr. Mrs. Miss Ms. Dr.
Name __________________________________________
Address ________________________________________
City ___________________________ State __________
ZIP ______________________ County _______________
Age
Phone ______________________________________ Day
___________________________________ Evening
E-mail __________________________________________
( )
( )
2. WHO IS YOUR COMPLAINT AGAINST?
Name/Firm ______________________________________
______________________________________
Address ________________________________________
________________________________________
City ___________________________ State __________
ZIP ______________________ County _______________
Phone __________________________________________
E-mail __________________________________________
Person you dealt with ______________________________
( )
18-24 25-34 35-44 45-54 55-64 65+
The Consumer Protection Division will send a copy of your complaint to the
respondent firm or licensed professional. This office cannot disclose your complaint
against a licensed professional to the public unless this office files a disciplinary
action against the licensed professional. This office represents the State of Indiana
and is limited in the remedies it can pursue. You may be entitled to compensation
or other rights that we cannot pursue for you. In addition to filing this complaint, you
may want to consider contacting a private attorney or your local small claims court.
MAIL COMPLETED FORMS TO:
Attorney General Greg Zoeller
Consumer Protection Division
Government Center South, 5
th
floor
302 West Washington Street
Indianapolis, IN 46204
PH: 317-232-6330 • FAX: 317-233-4393
www.IndianaConsumer.com
I affirm, under the penalties for perjury, that the foregoing representations, and those in all attachments, are true. The information I
have provided in this complaint form is based upon my personal knowledge. I consent to the Consumer Protection Division obtaining or
releasing any information in furtherance of the disposition of this complaint. I understand that I should not include my Social Security
Number in any information submitted to the Consumer Protection Division. If I do provide my Social Security Number, I expressly consent
to the disclosure of my Social Security Number in accordance with Indiana Code § 4-1-10-5(2).
Your Signature Date
When? _______________________________________ Action taken? __________________________________________
__________________________________________
Please attach a copy of all papers involved (order blank, warranty, credit card receipt and statement, invoice, contract or written agreement, advertisement, cancelled
check, correspondence and all other related documents). Please print clearly or type. DO NOT INCLUDE YOUR SOCIAL SECURITY NUMBER.
Rev. 01-09
11. WITH WHAT OTHER AGENCY HAVE YOU FILED THIS COMPLAINT?
When? _______________________________________ Action taken? __________________________________________
12. HAVE YOU CONTACTED A PRIVATE ATTORNEY? Yes No
13. HAVE YOU STARTED A COURT ACTION? IF YES, PLEASE ATTACH A COPY OF ALL COURT PAPERS. Yes No
14. HAVE YOU BEEN SUED OVER THIS ISSUE? IF YES, PLEASE ATTACH A COPY OF ALL COURT PAPERS. Yes No
17. HOW WOULD YOU LIKE YOUR COMPLAINT RESOLVED?
18. CONSENT AND VERIFICATION
16. PLEASE DESCRIBE YOUR COMPLAINT IN DETAIL (ATTACH ADDITIONAL PAGES IF NECESSARY)
10. HAVE YOU COMPLAINED TO THE BUSINESS? (Check box when applicable) Yes No
WHAT WILL HAPPEN NOW? WHAT ELSE SHOULD YOU DO?
15. DOLLAR AMOUNT ASSOCIATED WITH YOUR LOSS, IF ANY. $__________
