Consumer Complaint Form
Consumer Complaint Form. This is a Ohio form and can be use in Attorney General Office Statewide.
Tags: Consumer Complaint Form, Ohio Statewide, Attorney General Office
CONSUMER COMPLAINT FORM Office Use Only: Complaint #: The Ohio Attorney General’s 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. YOU MAY FILE A COMPLAINT ONE OF THREE WAYS: By phone: By mail: Complete this form in dark ink and mail to: Call 1‐800‐282‐0515 Consumer Protection Section Our help center 30 E. Broad St., 14th floor associates will assist you in filing your complaint. Columbus, OH 43215‐3400 Online: Visit www.OhioAttorneyGeneral.gov On our Web site, you can file a complaint, sign up for our e‐newsletter and learn about your consumer rights. PRE ‐ COMPLAINT QUESTIONS • Have you contacted the company about your complaint? Yes No • Have you hired an attorney to represent you in this matter? Yes No If yes, provide: Attorney’s name: Attorney’s phone number: ( ) • Are you involved in a lawsuit regarding this issue? Yes No • Have you contacted any other agencies regarding this issue? Yes No If yes, please list the agencies: 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. INFORMATION ABOUT YOU (THE CONSUMER) First name: Address: City: State: Daytime phone: ( ) E‐mail address: MI: Last name: Suffix: ________ ___ _ ___ County: Country: Zip Code: Alternate phone: ( ) Fax: ( ) SUBJECT OF THE COMPLAINT — BUSINESS INFORMATION Name of business you’re complaining about: Address: City: State: Zip Code: County: Country: ________ ___ ___ _ ________ ___ _ Telephone: ( ) Toll‐free: ( ) Fax: ( ) E‐mail address: Web address: me of business owner/salesperson: Na American LegalNet, Inc. www.FormsWorkFlow.com ABOUT THE TRANSACTION 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. How did the first contact with the company occur? E‐mail Mail Fax Radio Home visit Store visit Infomercial Telephone call Internet auction Television Internet banner/Web site Word of mouth Magazine/Newspaper 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 (VIN—not your license plate number): Year of vehicle: New / Used (circle one) Under warranty / “AS IS” (circle one) Mileage at purchase or lease: Current mileage: ACKNOWLEDGMENT OF TERMS AND CONDITIONS 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 General’s 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 COMPLAINT FORM, PART 2 Office Use Only: Complaint #: When you file a consumer complaint with the Ohio Attorney General’s 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 General’s 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 Warranty / Service Agreement HUD 1 Settlement Statement (Residential Mortgage Transactions Only) Invoice / Billing Statement Payment Record / Receipt Advertisement Debt Collection Account Number* (Debt Collection Complaints Only): 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 Federal Poverty Guidelines (2009) Disaster victim Income below 250% of federal poverty guideline (see chart) Non‐English speaking Person with disability Over the age of 60 Number of people 250% of federal in your family: poverty guideline: 1………… $27,075 2………… $36,425 3………… $45,775 4………… $55,125 5………… $64,475 6………… $73,825 7………… $83,175 8………… $92,525 American LegalNet, Inc. www.FormsWorkFlow.com