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Your Information Fields marked with (*) are required.Bureau of Consumer Protection15th Floor, Strawberry SquareHarrisburg, PA 171201-800-441-2555 226 PA ONLY1firstname.lastname@example.org Please check if you or an immediate family member is a member of the military or a veteran.Please check if you are age 60 or older. NAME*STREET ADDRESS*CITY* STATE*5-DIGIT ZIP CODE* COUNTY*BEST PHONE NUMBER* ALTERNATIVE PHONE NUMBEREMAIL AGE Complaint Information Fields marked with (*) are required. BUSINESS NAME*PERSON TO WHOM YOU SPOKEBUSINESS ADDRESSCITY* STATE5-DIGIT ZIP CODE BUSINESS PHONE NUMBER American LegalNet, Inc. www.FormsWorkFlow.com PRODUCT O SERVICE PURCHASED DATE PURCHASED PURCHASED PRICE FORM OF PAYMENT: CREDIT CARD ATM/DEBIT CARD PREPAID CARD OTHER WHERE AND HOW DID YOU SIGN THE CONTRACT (IF APPLICABLE): HOME (PAPER CONTRACT) þ HOME (OVER THE PHONE) HOME (ELECTRONIC SIGNATURE BUSINESS LOCATION OTHER WHERE AND HOW DID YOU SIGN THE CONTRACT?PLEASE CHECK IF YOU ARE OR HAVE EVER BEEN INVOLVED IN A LEGAL ACTION RELATED TO THIS COMPLAINT. IF SO, PLEASE SUMMARIZE IN TWO SENTENCES THE RESULT OF THE LEGAL ACTION. PLEASE EXPLAIN YOUR COMPLAINT: Try to be brief, but be sure to tell WHAT happened, WHEN it happened and WHERE it happened. Be speci037c about any oral statements the business made to you, ESPECIALLY those that in036uenced you to deal with the company, including how you heard about the company. Describe events in the order in which they happened. American LegalNet, Inc. www.FormsWorkFlow.com WHAT WOULD YOU LIKE THE BUSINESS TO DO TO RESOLVE YOUR COMPLAINT? HAVE YOU CONTACTED OTHER AGENCIES? YES NO IF YES, AGENCIES CONTACTED AND ACTIONS THEY TOOK (IF KNOWN) Optional Information HOW DID YOU HEAR ABOUT US?WHAT IS YOUR RACE OR ETHNICITY?HISPANIC/LATINOWHITE (NOT HISPANIC/LATINO) BLACK/AFRICAN AMERICAN (NOT HISPANIC/LATINO) NATIVE HAWAIIAN/PACIFIC ISLANDER ASIAN NATIVE AMERICAN BIRACIAL OTHER PLEASE READ CAREFULLY 035e Attorney General cannot act as your private attorney. As a law enforcement agency, the primary function of the O034ce of Attorney General is to represent the public at large by enforcing laws prohibiting unfair or deceptive practices. 035e Attorney General, through the Bureau of Consumer Protection, provides a mediation service to consumers where an attempt may be made to mediate your individual consumer complaint if it falls within the jurisdiction of the o034ce. Please be advised that the information you provide will be shared with the party against which you have 037led a complaint. Additionally, your complaint may be shared with or referred to other governmental law enforcement or regulatory agencies. Your complaint will also be kept on 037le with our o034ce and the information contained therein may be used to establish violations of Pennsylvania Law. Attached to this complaint form is an informational sheet which will help you in completion of the complaint form and also will explain in greater detail the mediation process. By signing below, I authorize the Bureau of Consumer Protection to contact the party(ies) against which I have 037led a complaint in an e033ort to reach an amicable resolution. I further authorize the party(ies) against which I have 037led a complaint to communicate with and provide information related to my complaint to the Bureau of Consumer Protection. I verify that I have read and understand the informational sheet about this process; and, that the information provided is true and correct to the best of my knowledge, information and belief. YOUR SIGNATURE þ DATE Please include copies of all documents regarding your problem. Be sure to send COPIES, not originals. American LegalNet, Inc. www.FormsWorkFlow.com Bureau of Consumer Protection15th Floor, Strawberry SquareHarrisburg, PA 171201-800-441-2555 226 PA ONLY1email@example.com WHEN SHOULD YOU FILE A COMPLAINTNOTE: (1) Participation in the mediation process is voluntary and we cannot compel a business to cooperate; and (2) We cannot mediate a matter that is already or has been the subject of legal action.We may refer your complaint to a local, state or federal agency, which has primary jurisdiction over the subject matter. If your complaint is referred to such an agency or organization, you will If your complaint falls with the Bureau222s jurisdiction, we may attempt to initiate our voluntary NOTE: Because of the volume of complaints the Bureau receives, it may take some time before we review and process your complaint. We ask for and appreciate your patience during this time.NOTE: the business to be in writing. TO HELP US HELP YOU, PLEASE REFRAIN FROM CALLING FOR 223STATUS REPORTS.224PROBLEM-SOLVING TIPSNOTE: If your claim involves a dispute of charges placed on your credit card, or billing statement or if a merchant right to challenge a charge. Under the Federal Fair Credit Billing Act, your credit card company must receive American LegalNet, Inc. www.FormsWorkFlow.com IDENTIFY THE PROBLEMGATHER RECORDSWRITING A COMPLAINT LETTEROTHER ASSISTANCEThank you for bringing this matter to our attention. We hope we can be of assistance to you. American LegalNet, Inc. www.FormsWorkFlow.com