CONSUMER COMPLAINT FORM

OFFICIAL CONSUMER COMPLAINT

Form ID: [FORM ID]
Date Submitted: [DATE]

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I. COMPLAINANT INFORMATION

A. Primary Contact Information

Full Name: _______________________________________________

Mailing Address:
Street: ___________________________________________________
City: ________________________ State: ______ ZIP: ____________

Phone Numbers:
Primary: () -
Alternative: () -

Email Address: __________________________________________

B. Alternative Contact Information

Authorized Representative: (if applicable)
Name: ____________________________________________________
Relationship to Complainant: _________________________________

Representative Contact Information:
Phone: (___) -
Email: ____________________________________________________

Preferred Method of Contact: (check one)
□ Phone
□ Email
□ Mail
□ Through Representative

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II. COMPANY INFORMATION

A. Company Identification

Legal Name of Business: ___________________________________

Doing Business As (DBA): _________________________________

Business Address:
Street: ___________________________________________________
City: ________________________ State: ______ ZIP: ____________

B. Company Contact Details

Business Phone: (___) -

Customer Service Phone: (___) -

Email Address: __________________________________________

Website: _______________________________________________

C. Company Representatives Contacted

1. Representative Name: __________________________________
   Title/Position: _______________________________________
   Date(s) of Contact: __________________________________
   Method of Contact: __________________________________

2. Representative Name: __________________________________
   Title/Position: _______________________________________
   Date(s) of Contact: __________________________________
   Method of Contact: __________________________________

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III. TRANSACTION DETAILS

A. Product or Service Information

Type of Product/Service: __________________________________

Brand/Manufacturer: _____________________________________

Model Number: _________________________________________

Serial Number: _________________________________________

Account Number: (if applicable) ___________________________

Service Type/Plan: (if applicable) __________________________

B. Purchase Information

Date of Purchase/Service Agreement: _______________________

Amount Paid: $__________________________________________

Payment Method: (check one)
□ Credit Card
□ Debit Card
□ Cash
□ Check
□ Electronic Transfer
□ Other: ________________________________________________

Purchase Location:
□ Physical Store
□ Online
□ Phone
□ Mail Order
□ Door-to-Door
□ Other: ________________________________________________

Store/Website Name: ____________________________________

Location/URL: _________________________________________

C. Contract or Agreement Details

Contract Type: _________________________________________

Contract Date: _________________________________________

Contract Term: _________________________________________

Contract/Agreement Number: _____________________________

Warranty Information: ___________________________________

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IV. COMPLAINT DETAILS

A. Complaint Summary

Provide a brief 1-2 sentence summary of your complaint

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B. Detailed Description of Complaint

Please provide a comprehensive chronological account of the problem. Include specific dates, times, locations, and factual information. Attach additional pages if necessary.

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C. Prior Contact with Company

Detail all previous attempts to resolve this issue directly with the company

First Contact:
Date: ____________________________________________________
Method: □ Phone □ Email □ Letter □ In Person □ Other: _________
Person Contacted: _________________________________________
Response Received: _______________________________________

Second Contact:
Date: ____________________________________________________
Method: □ Phone □ Email □ Letter □ In Person □ Other: _________
Person Contacted: _________________________________________
Response Received: _______________________________________

Additional Contacts: (attach separate sheet if necessary)

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D. Supporting Documentation

Check all documents you are submitting with this complaint

□ Purchase Receipt/Invoice
□ Contract/Agreement
□ Warranty Information
□ Product/Service Documentation
□ Correspondence with Company (emails, letters)
□ Photographs/Videos
□ Repair Records
□ Medical Records (if applicable)
□ Credit Card/Bank Statements
□ Advertisements/Marketing Materials
□ Other: ________________________________________________

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V. RESOLUTION REQUEST

A. Desired Resolution

Clearly state what specific action you want the company to take

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B. Monetary Relief Details

If seeking financial compensation, provide exact amount and calculation method

Amount Requested: $____________________________________

Calculation Method:

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Basis for Amount:

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VI. LEGAL AND REGULATORY INFORMATION

A. Applicable Consumer Protection Laws

The following laws may apply to your situation (check all that may apply)

□ Federal Trade Commission Act
□ Consumer Product Safety Act
□ Fair Credit Reporting Act
□ Fair Debt Collection Practices Act
□ Truth in Lending Act
□ Magnuson-Moss Warranty Act
□ State Consumer Protection Act: _____________________________
□ Other: ________________________________________________

B. Relevant Regulatory Agencies

The following agencies may have jurisdiction over this complaint

□ Federal Trade Commission (FTC)
□ Consumer Financial Protection Bureau (CFPB)
□ State Attorney General's Office
□ Better Business Bureau (BBB)
□ State Consumer Protection Agency
□ Industry-Specific Regulator: _______________________________
□ Other: ________________________________________________

C. Privacy Statement

The information provided in this complaint form is being collected for the purpose of addressing and resolving your consumer complaint. By submitting this form, you acknowledge and consent to the following:

1. Your complaint information may be shared with the company you are filing a complaint against to facilitate resolution.

2. Your complaint information may be shared with appropriate regulatory agencies that have jurisdiction over the matter.

3. Your personal identifying information (such as Social Security Number, financial account numbers, or medical information) will be redacted or protected in accordance with applicable privacy laws.

4. Statistical information derived from your complaint may be used in aggregate form for reporting purposes, policy development, or consumer education.

5. Your complaint and related documentation may become part of the public record if legal proceedings are initiated.

6. You have the right to request access to your personal information and to request corrections to any inaccurate information.

7. Your information will be retained in accordance with applicable record retention policies and laws.

D. Certification of Truth

By signing below, I certify that:

1. All information provided in this complaint form and in any attachments is true, accurate, and complete to the best of my knowledge and belief.

2. I understand that providing false or misleading information may result in the dismissal of my complaint and could potentially subject me to civil or criminal penalties under applicable laws.

3. I am authorized to file this complaint, either as the directly affected consumer or as the authorized representative of the affected consumer.

4. I understand that this complaint does not guarantee a resolution to my satisfaction and does not constitute legal action against the company.

5. I acknowledge that filing this complaint does not toll or extend any applicable statutes of limitations for bringing legal action related to this matter.

Signature: ____________________________________________

Printed Name: ________________________________________

Date: ________________________________________________

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VII. ADDITIONAL INFORMATION

A. Complaint Timeline

Upon receipt of your completed complaint form, the following timeline generally applies:

1. Initial Review (1-3 business days): Your complaint will be reviewed for completeness and jurisdiction.

2. Acknowledgment (3-5 business days): You will receive confirmation that your complaint has been received.

3. Company Notification (5-10 business days): The company will be notified of your complaint and given an opportunity to respond.

4. Company Response Period (10-30 business days): The company is typically given this timeframe to investigate and respond to your complaint.

5. Mediation/Resolution (30-60 business days): If necessary, mediation efforts may be undertaken to resolve the complaint.

6. Final Determination (60-90 business days): You will be notified of the outcome of your complaint.

Note: Complex cases may require additional time. Timelines may vary depending on the agency processing your complaint and the nature of the issues involved.

B. Follow-up Process

To check on the status of your complaint:

1. Reference Number: Use the complaint reference number provided in your acknowledgment communication.

2. Contact Methods:

   • Phone: [AGENCY PHONE NUMBER]
   • Email: [AGENCY EMAIL]
   • Online Portal: [AGENCY WEBSITE]

3. Information Required for Status Updates:

   • Complaint Reference Number
   • Your Name
   • Date Complaint Was Filed

C. Escalation Procedures

If your complaint is not resolved to your satisfaction, you may escalate as follows:

1. Request Supervisor Review: Contact the complaint department and request that a supervisor review your case.

2. Appeal Process: Submit a written appeal within 30 days of receiving the determination, clearly stating the reasons you believe the determination was incorrect.

3. Contact Higher Authority: File a complaint with the appropriate regulatory agency listed in Section VI.B.

4. Alternative Dispute Resolution: Consider mediation or arbitration services.

5. Legal Action: Consult with an attorney regarding potential legal remedies, including small claims court or other civil proceedings.

D. Complaint Reference Number

(For Official Use Only)

Complaint Reference Number: ____________________________

Received By: _________________________________________

Date Received: _______________________________________

Assigned To: _________________________________________

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VIII. SUBMISSION INSTRUCTIONS

1. Complete all applicable sections of this form.

2. Attach copies (not originals) of all supporting documentation.

3. Sign and date the Certification of Truth section.

4. Keep a copy of the completed form and all attachments for your records.

5. Submit your complaint via one of the following methods:

   Mail:
   [AGENCY NAME]
   [STREET ADDRESS]
   [CITY, STATE ZIP]

   Email:
   [EMAIL ADDRESS]

   Online:
   [WEBSITE URL]

   Fax:
   [FAX NUMBER]

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This form is designed to help consumers document and seek resolution for complaints against businesses. Completion of this form does not guarantee a favorable resolution to your complaint and does not constitute legal advice or create an attorney-client relationship. If you need legal advice, please consult with a qualified attorney.