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Consumer Complaint Form. This is a Nevada form and can be use in Office Of Attorney General Statewide.
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Tags: Consumer Complaint Form, Nevada Statewide, Office Of Attorney General
STATE OF NEVADA
OFFICE OF THE ATTORNEY GENERAL
BUREAU OF CONSUMER PROTECTION
555 East Washington Avenue, Suite 3900 Las Vegas, Nevada 89101
Telephone (702) 486-3786 · Fax (702) 486-3283
CONSUMER COMPLAINT FORM
Thank you for taking the time to complete this complaint form. Upon receipt of your complaint, a member of our
staff will review your complaint. This process can be lengthy. It may take from two to eight weeks to get a
response depending on the circumstances and the information you are able to provide with your complaint.
INSTRUCTIONS: Please type or print your complaint in ink and complete the form fully.
SECTION 1.
YOUR COMPLAINT IS AGAINST
CONSUMER COMPLAINT
Your First Name: __________________________
Individual/Business: _______________________ ______
Your Last Name: __________________________
If Business, Contact Person: _______________________
Your Address: ____________________________
Individual/Business Address: ______________________
________________________________________
(City)
(State)
(Zip)
_____________________________________________
(City)
(State)
(Zip)
Your Phone Number (#):____________________
Individual/Business Phone #:_______________________
Your Mobile #: ___________________________
Individual/Business Mobile #: ____________ __________
Your Fax #: ______________________________
Individual/Business Fax #:_________________________
Your Email: ______________________________
Individual/Business Email: _________________________
Your Date of Birth: ________________________
Individual/Business Web Site: ______________________
SECTION 2.
Did you make any payments to this individual or business?
If yes, please provide:
Yes_______ No ________
Date of payments: _______________________________________________________________________________
Form of payments: ______________________________________________________________________________
Total amount of payments: ________________________________________________________________________
SECTION 3.
Please detail the nature of your complaint against the above named individual or business. Include the “who,
what, when, why, and where” of your complaint. You may use additional sheets if necessary.
My complaint is: _______________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Consumer Complaint Form: Page 1 of 2
Rev: 4/25/08
American LegalNet, Inc.
www.FormsWorkFlow.com
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
SECTION 4.
List and attach photocopies (no originals) of any relevant documents, agreements, correspondence, or
receipts that support your complaint. Copy both sides of any canceled checks that pertain to this complaint.
a
_______________________________________________________________________________________
b.
_______________________________________________________________________________________
c.
_______________________________________________________________________________________
d.
_______________________________________________________________________________________
e.
_______________________________________________________________________________________
f.
_______________________________________________________________________________________
g.
_______________________________________________________________________________________
h.
_______________________________________________________________________________________
i.
_______________________________________________________________________________________
SECTION 5.
Sign and date this form. The Bureau of Consumer Protection cannot process any unsigned, incomplete, or
illegible complaints.
I understand that the Attorney General is not my private attorney, but rather represents the public by enforcing laws
prohibiting fraudulent, deceptive or unfair business practices. I understand that the Bureau of Consumer Protection
does not represent private citizens seeking refunds or other legal remedies. I am filing this complaint to notify the
Bureau of Consumer Protection of the activities of a particular business or individual. I understand that the information
contained in this complaint may be used to establish violations of Nevada law in both private and public enforcement
actions. I authorize the Bureau of Consumer Protection to send my complaint and supporting documents to the
individual or business identified in this complaint. I understand that this complaint is also subject to disclosure under
Nevada’s Public Record Law.
I certify that the information provided on this form is true and correct to the best of my knowledge.
___________________________________________
(Signature)
______________________________________________
(Print Name)
Date: ______________________________________
___________________________________________
(Signature)
______________________________________________
(Print Name)
Date: ______________________________________
Consumer Complaint Form: Page 2 of 2
Rev: 4/25/08
American LegalNet, Inc.
www.FormsWorkFlow.com