Antitrust Complaint Form antitrust@attorneygeneral.gov Antitrust Section th 14 Floor, Strawberry Square Harrisburg, PA 17120 1-717-787-4530 Required fields are marked with an asterisk* Your information: Age Group: Are you a veteran? Are you on active duty? Yes Yes Name* No No Under 18 18-34 35-59 60-64 65 and older www.attorneygeneral.gov Mr. Mrs. Address* Ms. Dr. City* State* Zip Code* County* Daytime Phone Number* ( ) Home Phone Number* ( ) Email Address If completing this form on behalf of someone else, please complete the following information: Age Group: Are they a veteran? Are they on active duty? Yes Yes No No Under 18 18-34 35-59 60-64 65 and older Mr. Mrs. Address* Ms. Dr. Name* City* State* Zip Code* County* Daytime Phone Number ( ) Home Phone Number ( ) Email Address If your complaint involves a merger: What industry is involved? Who are the merging parties? How will you be impacted by the merger? What would you like us to do? American LegalNet, Inc. www.FormsWorkFlow.com If your complaint involves price fixing (where competitors agree on a price or other terms of sale for their products or services): What industry is involved? What are the specific products or services? Who is engaging in the conduct? Where is the conduct occurring? Describe the conduct. Why do you think the conduct is price fixing? How are you impacted by the conduct? What would you like us to do? Is there anyone else we should contact for more information? If your complaint involves bid-rigging (where competitors agree in advance who will submit the winning bid): What is the name of the public or private entities involved in the bid or contract? What is the product or service put out for bid? Where did the conduct occur? Who submitted bids? Who won the bid/contract? Describe the bidding process and your concerns about the process. How were you impacted? What would you like us to do? Is there anyone else we should contact for more information? American LegalNet, Inc. www.FormsWorkFlow.com Please explain your complaint. You may use additional sheets if necessary. Please print or type clearly. Try to be brief, but be sure to tell us WHAT happened, WHEN it happened, and WHERE it happened and WHAT you would like us to do. Be specific about any oral statements that were made to you. Describe events in the order in which they happened. PLEASE READ CAREFULLY THE ATTORNEY GENERAL CANNOT ACT AS YOUR PRIVATE ATTORNEY As a law enforcement agency, the primary function of the Office of Attorney General is to represent the public at large. The Antitrust Section will review all complaints received. If additional information is required, you will be contacted. Your complaint will remain on file with our office and the information contained in it may be used to establish violations of Pennsylvania Law. This office cannot release any information about a review or investigation it may undertake. I certify that the information provided is true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. � 4904, relating to unsworn falsification to authorities. YOUR SIGNATURE DATE American LegalNet, Inc. www.FormsWorkFlow.com