FRANCHISE-RELATED COMPLAINT FORM ATTORNEY GENERAL ANDREW M. CUOMO Office of the New York State Attorney General Investor Protection Bureau, Franchise Section 120 Broadway, 23rd Floor New York, NY 10271-0332 Tel. (212) 416-8200 Fax (212) 416-6042 http://WWW.OAG.STATE.NY.US 1. 2. 3. 4. PLEASE BE SURE TO COMPLAIN TO THE FRANCHISOR BEFORE FILING. PLEASE TYPE OR PRINT CLEARLY IN DARK INK. YOU MUST COMPLETE THE ENTIRE FORM. INCOMPLETE OR UNCLEAR FORMS WILL BE RETURNED TO YOU. MAKE SURE YOU ENCLOSE COPIES OF IMPORTANT PAPERS CONCERNING YOUR TRANSACTION. INFORMATION ABOUT PURCHASER OR COMPLAINANT (YOU). YOUR NAME AND BUSINESS NAME HOME & CELL TELEPHONE NUMBERS: STREET ADDRESS BUSINESS TELEPHONE NUMBER: CITY/TOWN COUNTY STATE ZIP INFORMATION ABOUT FRANCHISOR OR SELLER. ARE YOU WILLING TO BE INTERVIEWED BY THIS OFFICE? YES G NO G ARE YOU WILLING TO BE A WITNESS IF FORMAL PROCEEDINGS ARE COMMENCED BY THE NEW YORK STATE ATTORNEY GENERAL? YES G NO G NAME STREET ADDRESS STATE ZIP CITY/TOWN TELEPHONE NUMBER: CELL PHONE NUMBER: DID YOU SIGN A CONTRACT? FRANCHISE FEE AMOUNT PAID: G Yes G No TOTAL INVESTMENT: HOW WAS FRANCHISE FEE PAID? ~ lump sum ~ Installments Other____________________ WHERE DID YOU SIGN THE CONTRACT? DATE SIGNED: DID ANY NEGOTIATIONS OR OFFER TAKE PLACE IN NEW YORK? G Yes G No WHAT FORM OF RELIEF ARE YOU SEEKING, e.g., RETURN OF FRANCHISE FEE? LIST ANY ORAL REPRESENTATIONS OR PROMISES MADE TO YOU: WHAT IF, ANY, MATERIAL STATEMENTS MADE TO YOU WERE UNTRUE? WAS FRANCHISE INVESTMENT ADVERTISED? WHERE ADVERTISED? DATE ADVERTISED: G Yes G No HAS YOUR FRANCHISE EVER OPENED? IS YOUR FRANCHISE CURRENTLY OPEN OR CLOSED? G Yes G No G Open G Closed IF OPENED, WHEN DID IT OPEN? IF CLOSED, WHEN DID IT CLOSE? American LegalNet, Inc. www.FormsWorkflow.com DID YOU COMPLAIN TO THE COMPANY OR INDIVIDUAL? PERSON(S) CONTACTED: JOB TITLE: G Yes G No IF YES, HOW DID YOU COMPLAIN? G By Telephone G In Person G By Mail G By Email NATURE OF RESPONSE: DATE OF RESPONSE: HAS MATTER BEEN SUBMITTED TO ANOTHER AGENCY OR ATTORNEY? (If “Yes,” give name and address) G Yes No G IS COURT ACTION PENDING? (Please describe as necessary) Briefly describe your complaint and the outcome you want (please attach extra pages if necessary). Did someone refer you to this office? FYes F No If so, who? READ THE FOLLOWING BEFORE SIGNING BELOW. PLEASE attach PHOTOCOPIES of any relevant documents, such as correspondence, agreements, etc. DO NOT SEND ORIGINALS. NOTE: In order to resolve your complaint we may send a copy of this form to the individual or company about whom you are complaining. In filing this complaint, I understand that the Attorney General is not my private attorney, but represents the public. I also understand that if I have any questions concerning my legal rights or responsibilities, I should contact a private attorney. I have no objection to the contents of this complaint being forwarded to the individual or company the complaint is directed towards, or to another agency if my complaint is referred to that agency. The above complaint is true and accurate to the best of my knowledge. I also understand that any false statements made in this complaint are punishable as a Class A Misdemeanor under § 175.30 and/or §210.34 of the Penal Law. Signature____________________________________ Date: ____________________ º º Remember to enclose COPIES of any documentation with regard to this complaint. Mail to: OFFICE OF THE NEW YORK STATE ATTORNEY GENERAL Investor Protection Bureau, Franchise Section 120 Broadway, 23rd Floor New York, New York 10271 American LegalNet, Inc. www.FormsWorkflow.com