Consumer Complaint Form | NYS Department of State

CONSUMER INFORMATION

Title:

*Last Name:

*First Name:

*Street Address:

*City:

*State:

*Zip Code:

*Phone (Day):

Phone (Eve):

Fax:

*Email Address:

*Have you ever served in the military?

Yes No

COMPANY INFORMATION

*Company or Seller:
Representative/ Salesperson & Title:

*Street Address:

City:

*State:

*Zip Code:

Company Phone:

Company Fax:

Website Address:
License Number: (if applicable)

COMPLAINT INFORMATION

* Description of Complaint:

Please type a clear description of the complaint (e.g., nature or type of complaint: car, mail order, telemarketing, internet, etc)

Date problem first occurred:	(MM/DD/YYYY)
Date(s) you complained to company:
To whom you complained:
Brand Name or Manufacturer:
Model Name or Number:
Serial Number:
Warranty Expiration Date:
Date Purchased:	(MM/DD/YYYY)
Contract, Acct. or Policy #:
Date Signed the Contract or Order:	(MM/DD/YYYY)

PAYMENT INFORMATION

Have you already paid for the product or service?

Yes No Partial Purchase

*Amount in Dispute:

Method of Payment:

Cash Check Credit Card Money Order Other

*Description of the Resolution you are Requesting:

(e.g., refund, credit, exchange or rebate)

Have you contacted any other government agency to assist in resolving this complaint? Yes No

Agency contacted:
Agency contact person:
Address:
Assistance Received:
Have you contacted an attorney:

Court action pending?

Yes No

ACKNOWLEDGE AND SUBMIT

Before you press the "Submit" button, please print a copy of the completed Consumer Complaint Form for your records. If you have supporting documentation regarding your complaint such as contracts, warranties, bills received, canceled checks, correspondence, etc., please mail or fax copies of these documents as well as a copy of the completed Consumer Complaint Form to the address at the bottom of this screen. DO NOT SEND ORIGINALS.

New York State Department of State
Division of Consumer Protection
Consumer Assistance Unit
99 Washington Avenue
Albany, New York 12231-0001
Fax: 518-486-3936

PLEASE READ THE FOLLOWING BEFORE SUBMITTING THIS FORM:

In filing this form, I understand that the Division of Consumer Protection (DCP) is attempting to mediate my complaint. I also understand that if I have any questions concerning my legal rights or responsibilities, I should contact a private attorney. I hereby authorize the DCP to work with the appropriate government and private sector entities on my behalf, including requesting and reviewing appropriate documents, to attempt to resolve my dispute. I have no objection to the contents of this complaint being forwarded to the business or service person the complaint is directed against. The above complaint is true and accurate to the best of my knowledge.

This document is subject to disclosure under the Freedom of Information Law. The person or firm you are complaining about will receive a copy of this complaint.

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Instructions

Printable Complaint Form