FIS 0590 (9/09) Office of Financial and Insurance Regulation Debt Management Complaint Form Michigan law, including PA 148 of 1975 as amended, authorizes the review of complaints involving Debt Management Companies. Completion of this form is voluntary and helps us review your claim. Today's date My Name Name of DEBT MANAGEMENT COMPANY this complaint is about Address Company Address City State Home phone number ( Zip City ( Zip Company phone number Work phone number ) State ) ( ) Name of the person or persons you dealt with at the Debt Management Company Have you hired an attorney to represent you in this matter? Yes No Have you filed a lawsuit in this matter? Yes No Please list events in the order they happened. Attach additional pages if needed. If possible, please use letter size paper (8 1/2 x 11") for all attachments. Details of my complaint: Reviewing documents often helps us understand important details of your complaint. Please attach copies of your debt mangement contract, letters or other documents that will help us review your complaint. Always send copies. Never send original documents. Please mail your complaint to: OFIR Consumer Services PO Box 30220 Lansing MI 48909-7720 Or fax to: (517) 241-3991 Or Email to: ofir-ins-info@michigan.gov I authorize the release of any information regarding this complaint to help the Office of Financial and Insurance Regulation with their review. A copy of this complaint and related documents may be sent to any company, agency or licensee involved in this matter. Signature Date signed Michigan Department of Energy, Labor & Economic Growth DELEG is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. Visit OFIR online at: www.michigan.gov/ofir Phone OFIR toll-free at: 1-877-999-6442 American LegalNet, Inc. www.FormsWorkFlow.com