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YOU MUST COMPLETE THE ENTIRE FORM. INCOMPLETE OR UNCLEAR FORMS WILL BE RETURNED TO YOU. MAKE SURE YOU ENCLOSE COPIES OF IMPORTANT PAPERS CONCERNING YOUR TRANSACTION. CONSUMER YOUR NAME HOME TELEPHONE NUMBER STREET ADDRESS BUSINESS TELEPHONE NUMBER CITY/TOWN COUNTY STATE ZIP NAME OF SELLER OR PROVIDER OF SERVICES NAME OF OTHER SELLER OR PROVIDER OF SERVICES TELEPHONE NUMBER DATE OF TRANSACTION COST OF PRODUCT OR SERVICE HOW PAID Check those which apply G Cash G Check G Credit Card G Other WHERE DID YOU SIGN THE CONTRACT DID YOU SIGN A CONTRACT G Yes DATE SIGNED WHERE WAS IT ADVERTISED DATE ADVERTISED G No WAS PRODUCT OR SERVICE ADVERTISED TYPE OF COMPLAINT e.g. car mail order etc. Use the reverse side of this form to provide details DATE YOU COMPLAINED TO THE COMPANY OR INDIVIDUAL PERSON CONTACTED JOB TITLE G By Mail G By Telephone G In Person NATURE OF RESPONSE HAS MATTER BEEN SUBMITTED TO ANOTHER AGENCY OR ATTORNEY If Yes give name and address IS COURT ACTION PENDING Please describe as necessary ADDITIONAL INFORMATION MANUFACTURER OF PRODUCT PRODUCT MODEL OR SERIAL NUMBER ADDRESS WARRANTY EXPIRATION DATE DID BUSINESS ARRANGE FINANCING If Yes give name and address of bank or finance company PLEASE DESCRIBE COMPLAINT ON REVERSE SIDE CFABFR 01/11 BRIEFLY DESCRIBE YOUR COMPLAINT WHAT FORM OF RELIEF ARE YOU SEEKING e.g. exchange repair or money back etc. WHO REFERRED YOU TO THIS OFFICE READ THE FOLLOWING BEFORE SIGNING BELOW PLEASE ATTACH TO THIS FORM PHOTOCOPIES of any papers involved contracts warranties bills received canceled checks correspondence etc.. DO NOT SEND ORIGINALS. NOTE In order to resolve your complaint we may send a copy of this form to the person or firm about whom you are complaining. In filing this complaint I understand that the Attorney General is not my private attorney but represents the public in enforcing laws designed to protect the public from misleading or unlawful business practices. Ag. ny. gov PLEASE BE SURE TO COMPLAIN TO THE COMPANY OR INDIVIDUAL BEFORE FILING. PLEASE TYPE OR PRINT CLEARLY IN DARK INK. YOU MUST COMPLETE THE ENTIRE FORM. INCOMPLETE OR UNCLEAR FORMS WILL BE RETURNED TO YOU. MAKE SURE YOU ENCLOSE COPIES OF IMPORTANT PAPERS CONCERNING YOUR TRANSACTION. CONSUMER YOUR NAME HOME TELEPHONE NUMBER STREET ADDRESS BUSINESS TELEPHONE NUMBER CITY/TOWN COUNTY STATE ZIP NAME OF SELLER OR PROVIDER OF SERVICES NAME OF OTHER SELLER OR PROVIDER OF SERVICES TELEPHONE NUMBER DATE OF TRANSACTION COST OF PRODUCT OR SERVICE HOW PAID Check those which apply G Cash G Check G Credit Card G Other WHERE DID YOU SIGN THE CONTRACT DID YOU SIGN A CONTRACT G Yes DATE SIGNED WHERE WAS IT ADVERTISED DATE ADVERTISED G No WAS PRODUCT OR SERVICE ADVERTISED TYPE OF COMPLAINT e.g. car mail order etc. Use the reverse side of this form to provide details DATE YOU COMPLAINED TO THE COMPANY OR INDIVIDUAL PERSON CONTACTED JOB TITLE G By Mail G By Telephone G In Person NATURE OF RESPONSE HAS MATTER BEEN SUBMITTED TO ANOTHER AGENCY OR ATTORNEY If Yes give name and address IS COURT ACTION PENDING Please describe as necessary ADDITIONAL INFORMATION MANUFACTURER OF PRODUCT PRODUCT MODEL OR SERIAL NUMBER ADDRESS WARRANTY EXPIRATION DATE DID BUSINESS ARRANGE FINANCING If Yes give name and address of bank or finance company PLEASE DESCRIBE COMPLAINT ON REVERSE SIDE CFABFR 01/11 BRIEFLY DESCRIBE YOUR COMPLAINT WHAT FORM OF RELIEF ARE YOU SEEKING e.g. exchange repair or money back etc. WHO REFERRED YOU TO THIS OFFICE READ THE FOLLOWING BEFORE SIGNING BELOW PLEASE ATTACH TO THIS FORM PHOTOCOPIES of any papers involved contracts warranties bills received canceled checks correspondence etc.. DO NOT SEND ORIGINALS. NOTE In order to resolve your complaint we may send a copy of this form to the person or firm about whom you are complaining. ATTORNEY GENERAL ERIC T. SCHNEIDERMAN STATE OF NEW YORK OFFICE OF THE ATTORNEY GENERAL BUREAU OF CONSUMER FRAUDS AND PROTECTION 350 Main Street - Main Place Tower Suite 300A Buffalo NY 14202-0341 Tel. 716 853-8404 Fax 716 853-8414 COMPLAINT FORM Consumer Hotline For Hearing Impaired 1 800 771-7755 TDD 1 800 788-9898 http //www. ag. ny. gov PLEASE BE SURE TO COMPLAIN TO THE COMPANY OR INDIVIDUAL BEFORE FILING. PLEASE TYPE OR PRINT CLEARLY IN DARK INK. YOU MUST COMPLETE THE ENTIRE FORM. INCOMPLETE OR UNCLEAR FORMS WILL BE RETURNED TO YOU. MAKE SURE YOU ENCLOSE COPIES OF IMPORTANT PAPERS CONCERNING YOUR TRANSACTION. CONSUMER YOUR NAME HOME TELEPHONE NUMBER STREET ADDRESS BUSINESS TELEPHONE NUMBER CITY/TOWN COUNTY STATE ZIP NAME OF SELLER OR PROVIDER OF SERVICES NAME OF OTHER SELLER OR PROVIDER OF SERVICES TELEPHONE NUMBER DATE OF TRANSACTION COST OF PRODUCT OR SERVICE HOW PAID Check those which apply G Cash G Check G Credit Card G Other WHERE DID YOU SIGN THE CONTRACT DID YOU SIGN A CONTRACT G Yes DATE SIGNED WHERE WAS IT ADVERTISED DATE ADVERTISED G No WAS PRODUCT OR SERVICE ADVERTISED TYPE OF COMPLAINT e.g. car mail order etc. Use the reverse side of this form to provide details DATE YOU COMPLAINED TO THE COMPANY OR INDIVIDUAL PERSON CONTACTED JOB TITLE G By Mail G By Telephone G In Person NATURE OF RESPONSE HAS MATTER BEEN SUBMITTED TO ANOTHER AGENCY OR ATTORNEY If Yes give name and address IS COURT ACTION PENDING Please describe as necessary ADDITIONAL INFORMATION MANUFACTURER OF PRODUCT PRODUCT MODEL OR SERIAL NUMBER ADDRESS WARRANTY EXPIRATION DATE DID BUSINESS ARRANGE FINANCING If Yes give name and address of bank or finance company PLEASE DESCRIBE COMPLAINT ON REVERSE SIDE CFABFR 01/11 BRIEFLY DESCRIBE YOUR COMPLAINT WHAT FORM OF RELIEF ARE YOU SEEKING e.g. exchange repair or money back etc. WHO REFERRED YOU TO THIS OFFICE READ THE FOLLOWING BEFORE SIGNING BELOW PLEASE ATTACH TO THIS FORM PHOTOCOPIES of any papers involved contracts warranties bills received canceled checks correspondence etc.