To prevent delay, please be sure to complete both sides of this form in full. Please print clearly or type. DO NOT include your Social
Security Number on this form or in any accompanying documents

1. YOUR INFORMATION

2. WHO IS YOUR COMPLAINT AGAINST?

3. WHEN DID TRANSACTION/INCIDENT OCCUR?

4. WHERE DID THE TRANSACTION/INCIDENT YOU ARE COMPLAINING ABOUT TAKE PLACE? (Check box when applicable)

5. WHAT WAS THE VERY FIRST CONTACT BETWEEN YOU AND THE FIRM?

6. DO YOU CONSENT TO DISCLOSING THE FOLLOWING TO THE PUBLIC?

7. WHAT WAS THE TRANSACTION FOR?

8. HOW DID YOU PAY?

9. DID YOU SIGN ANY WRITTEN AGREEMENT? IF YES, PLEASE ATTACH A COPY OF THE AGREEMENT.

10. HAVE YOU COMPLAINED TO THE BUSINESS? (Check box when applicable)

11. WITH WHAT OTHER AGENCY HAVE YOU FILED THIS COMPLAINT?

12. HAVE YOU CONTACTED A PRIVATE LAWYER

13. HAVE YOU STARTED A COURT ACTION? IF YES, PLEASE ATTACH A COPY OF ALL COURT PAPERS.

14. HAVE YOU BEEN SUED OVER THIS ISSUE? IF YES, PLEASE ATTACH A COPY OF ALL COURT PAPERS

15. Dollar amount associated with yourLOSS, IF ANY.

16. PLEASE DESCRIBE YOUR COMPLAINT IN DETAIL (ATTACH ADDITIONAL PAGES IF NECESSARY)

Please attach a copy of all papers involved (order blank, warranty, credit card receipt and statement, invoice, contract or written agreement, advertisement, cancelled check, correspondence and all other related documents). Please print clearly or type. DO NOT INCLUDE YOUR SOCIAL SECURITY NUMBER.

17. HOW WOULD YOU LIKE YOUR COMPLAINT RESOLVED?

18. CONSENT AND VERIFICATION

I affirm, under the penalties for perjury, that the foregoing representations, and those in all attachments, are true. The information I have provided in this complaint form is based upon my personal knowledge. I consent to NATIONAL CONSUMER RIGHTS COMMISSION obtaining or releasing any information in furtherance of the disposition of this complaint. I understand providing any wrong information found wrong the consumer rights commission have rights to file the case against me.

WHAT WILL HAPPEN NOW? WHAT ELSE SHOULD YOU DO?

The Consumer Protection Division will send a copy of your complaint to the respondent firm or licensed professional. This office cannot disclose your complaint against a licensed professional to the public unless this office files a disciplinary action against the licensed professional. This office represents the State of Indiana and is limited in the remedies it can pursue. You may be entitled to compensation or other rights that we cannot pursue for you. In addition to filing this complaint, you may want to consider contacting a private attorney or your local small claims court.