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Consumer Complaint Form - Ohio

Consumer Complaint Form Form. This is a Ohio form and can be used in Citizen Protection Attorney General Office Statewide .
 Fillable pdf Last Modified 9/4/2013
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Consumer Protection Office 800-282-0515 Fax 866-268-2279 30 E. Broad Street, 14th Floor Columbus, Ohio 43215 www.OhioAttorneyGeneral.gov Consumer Complaint Form Office Use Only: Complaint #: The Ohio Attorney General's Consumer Protection Section provides a complaint resolution process to resolve disputes between consumers and businesses. If you have a complaint regarding a consumer transaction (a purchase or advertisement of a product or service used for the home or personal use), you may file a complaint with our office. You May File a Complaint One of Three Ways: By mail: Complete this form in dark ink and mail to: Consumer Protection Section 30 E. Broad St., 14th floor Columbus, OH 43215-3400 By phone: Call 800-282-0515 Our help center associates will assist you in filing your complaint. Online: Visit www.OhioAttorneyGeneral.gov On our Web site, you can file a complaint, sign up for our e-newsletter and learn about your consumer rights. Pre-Complaint Questions: · Have you contacted the company about your complaint? · Have you hired an attorney to represent you in this matter? Yes Yes Yes Yes No No ) If yes, provide: Attorney's name: · Are you involved in a lawsuit regarding this issue? · Have you contacted any other agencies regarding this issue? Attorney's phone number: ( No No If yes, please list the agencies: PLEASE NOTE: Any information you submit with your complaint is considered public and may be released as part of a public records request. Remove Social Security numbers, credit card numbers, debit card numbers and other bank account numbers from any documents you submit with your complaint. Information about You (the Consumer): First name: Address: City: Daytime phone: ( E-mail address: ) MI: Last name: Suffix: State: Zip Code: County: Alternate phone: ( Fax: ( ) ) Country: Subject of the Complaint (Business Information): Name of business you're complaining about: Address: City: Telephone: ( E-mail address: Name of business owner/salesperson: American LegalNet, Inc. www.FormsWorkFlow.com State: ) Zip Code: Toll-free: ( ) County: Fax: ( Web address: ) Country: About the Transaction: Product/service involved: Date of purchase: / / How did the first contact with the company occur? (mm/dd/yyyy) No No E-mail Fax Home visit Infomercial Internet auction Disputed amount: $ Yes No Internet banner/Web site Magazine/Newspaper Mail Radio Store visit Telephone call Television Word of mouth Other: Did you sign a contract? Are you making payments? Yes Yes Total cost of product/service: $ Method of payment: Amount paid so far: $ Is the product/service under warranty? If yes, warranty company name: Describe the transaction and your complaint: Briefly describe what you would consider a reasonable resolution to your complaint: Motor Vehicle Complaints ONLY: Complete this section only if your complaint regards a motor vehicle: Make: Model: Purchase / Lease (circle one) Vehicle Identification Number (VIN--not your license plate number): Year of vehicle: Mileage at purchase or lease: New / Used (circle one) Current mileage: Under warranty / "AS IS" (circle one) Acknowledgment of Terms and Conditions: By checking this box I acknowledge that the information given above is true to the best of my knowledge and belief. I understand that any information I submit to the Ohio Attorney General's Office is considered public information and may be released in a public records request. I understand a copy of this form and all documents relating to my complaint will be forwarded to the company that is the subject of my complaint. I understand that the Ohio Attorney General cannot Date submitted: / / (mm/dd/yyyy) serve as my private attorney. American LegalNet, Inc. www.FormsWorkFlow.com Consumer Protection Office 800-282-0515 Fax 866-268-2279 30 E. Broad Street, 14th Floor Columbus, Ohio 43215 www.OhioAttorneyGeneral.gov Office Use Only: Complaint #: Consumer Complaint Form, Part 2 When you file a consumer complaint with the Ohio Attorney General's Office, you also must submit copies of documents related to your complaint, such as contracts and receipts. Submitting these documents helps ensure that you will get the best possible results from our complaint resolution process. Failure to provide required documentation may prevent or delay our ability to help you. Please send this form and copies of any documents related to your complaint to the Attorney General's Office: Consumer Protection Section, 30 E. Broad St., 14th floor, Columbus, OH 43215-3400 DO NOT SEND ORIGINALS. Any documents sent to our office will be scanned electronically and then destroyed. PLEASE NOTE: Any information you submit with your complaint is considered public and may be released as part of a public records request. Remove Social Security numbers, credit card numbers, debit card numbers and other bank account numbers from any documents you submit with your complaint. Documents to Submit with Your Complaint: Check below to indicate which documents/items you are submitting with your complaint (check all that apply): Contract / Purchase Agreement Warranty / Service Agreement Invoice / Billing Statement Payment Record / Receipt Advertisement Estimate / Proposal Loan Application *DO NOT SUBMIT YOUR BANK ACCOUNT NUMBER OR SOCIAL SECURITY NUMBER. HUD 1 Settlement Statement (Residential Mortgage Transactions Only) Debt Collection Account Number* (Debt Collection Complaints Only): Other: Additional Information about You: To help our office better serve Ohio consumers, please check any/all categories that apply to you (optional): Active service member or immediate family of active service member Disaster victim Income below 250% of federal poverty guideline (see chart) Non-English speaking Person with disability Over the age of 65 Federal Poverty Guidelines (2013) Number of people in your family: 250% of federal poverty guideline: $28,725 $38,775 $48,825 $58,875 $68,925 $78,975 $89,025 $99,075 American LegalNet, Inc. www.FormsWorkFlow.com 1............ 2............ 3............ 4............ 5............ 6............ 7............ 8............
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