Fillable (775) 684 - 4690 dmvnv.com COMPLAINT VOLUNTARY STATEMENT (Department of Motor Vehicles )

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CED20 (7/2017)
Compliance Enforcement Division
555 Wright Way
Carson City, Nevada 89711
(775) 684 - 4690
dmvnv.com
COMPLAINT VOLUNTARY STATEMENT
I wish to file a complaint against the business or individual named below. I understand that the Department of Motor Vehicles
DOES NOT represent private citizens seeking return of money or other personal remedies as a result of contractual disputes
or civil actions.
Person Filing Complaint:
Name _______________________________________________________Day Time Phone ______________________
Address _____________________________________________________Home Phone _________________________
City ___________________________State ____________Zip __________Email Address ________________________
Business or Individual Complaint Filed Against: Business License No _____________________
(If applicable)
Business/Individual Name ____________________________________Phone __________________________________
Address__________________________________________________________________________________________
Street City State Zip code
Representative’s Name _____________________________________________________________________________
Vehicle Involved: (If applicable)
VIN
Year _______________Make _______________________Model ____________________Color ___________________
Other complaint not involving a motor vehicle sale or repair.
Explain Complaint: (Please attach copies of any documents you have to support your complaint.)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Payments
Did you make payments? Yes No If yes, to whom: _____________________________________________
How much did you pay? ____________________________ Dates of any payments: ______________________________________
Method of payment (cash, check, credit, money order, cashier’s check): __________________________________________________
CED20 (7/2017)
Compliance Enforcement Division
555 Wright Way
Carson City, Nevada 89711
(775) 684 - 4690
www.dmvnv.com
Contracts
Did you sign a Contract, Waiver, or Invoice: Yes No If yes, date signed ____________________________
Identify your attempts to resolve the issue(s) with the company, corporation, or organization:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Other Agencies
Have you contacted another agency for assistance? Yes No
If yes, which agency? _____________________________________ Case/Ref# ________________________________
I, _______________________________________________ freely and voluntarily give this affidavit to the State of Nevada,
Department of Motor Vehicles. I understand that the Department of Motor Vehicles - Compliance Enforcement Division does
NOT investigate complaints against towing, impound services, or insurance disputes, or help to get a refund or cancel a
sale. I further certify and affirm that all information is true and correct to the best of my knowledge and that I will testify to these facts if
requested to do so in any action brought against the business or individual named above. Signatures must be original. Photocopies
are not acceptable.
___________________________________________________ ________________________________
Signature of Complainant Date
___________________________________________________ ________________________________
Signature of Notary or Authorized DMV Representative Date
Forward the completed form to your local Compliance Enforcement Division office as listed below.
SOUTHERN NEVADA
Department of Motor Vehicles
Compliance Enforcement Division
8250 West Flamingo Road
Las Vegas, NV 89147
NORTHERN NEVADA
Department of Motor Vehicles
Compliance Enforcement Division
9155 Double Diamond Pkwy
Reno, NV 89521
FOR OFFICIAL USE ONLY – DO NOT WRITE IN THIS BOX
Case Number:
File Date:
Tech ID:
Office:
Business Name:
Bus. Lic. Number:
Notes:
Received:
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Completed 24 December 2020

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