Fillable COMPLAINT FORM STATE OF NEVADA OFFICE OF THE (State of Nevada, Department of Information Technology)

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COMPLAINT FORM STATE OF NEVADA OFFICE OF THE (State of Nevada, Department of Information Technology)

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The COMPLAINT FORM STATE OF NEVADA OFFICE OF THE (State of Nevada, Department of Information Technology) form is 5 pages long and contains:

  • 1 signature
  • 9 check-boxes
  • 107 other fields

Country of origin: US
File type: PDF

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BROWSE STATE OF NEVADA, DEPARTMENT OF INFORMATION TECHNOLOGY (NV) FORMS

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Facebook: /NVAttorneyGeneral Twitter: @NevadaAG YouTube: NevadaAG
Page 1 of 5
STATE OF NEVADA
OFFICE OF THE ATTORNEY GENERAL
100 N. CARSON ST., CARSON CITY, NV 89701 – TEL# 775-684-1100 – FAX# 775-684-1108
555 E. WASHINGTON AVE., STE 3900, LAS VEGAS, NV 89101 – TEL# 702-486-3420 – FAX# 702-486-3768
COMPLAINT FORM
If you have a life-threatening emergency or are in immediate danger, please contact local law
enforcement by dialing 911 on your telephone or cellular phone. The information you provide
on this form may be used to help us investigate violations of state laws therefore it is important to
complete all required fields. The length of this process can vary depending on the circumstances
and information you provide. Please note: The Attorney General cannot provide you with legal
advice or represent you in personal legal actions. If you cannot afford a private attorney, you may
consider contacting your local legal aid office.
***ONLY COMPLAINTS THAT ARE SIGNED WILL BE PROCESSED***
***PLEASE WRITE LEGIBLY***
HAVE YOU PREVIOUSLY FILED A COMPLAINT REGARDING YOUR CONCERN WITH
OUR OFFICE? YES NO
If so, what was the approximate date(s) of the previously filed complaint(s)?
SECTION 1: COMPLAINANT INFORMATION (Please enter your contact information.)
Prefix (choose one):
□
Mr.
□
Mrs.
□
Ms.
□
Miss.
□
Dr.
First Name: Middle Name:
Last Name:
Suffix (choose one): □ Jr. □ Sr. □ I □ II □ III □ IV □ Other _____
Your Organization or Company Name if filing on behalf of your Organization or Company:
Street Address:
City:
State:
Zip Code:
Preferred Phone Number:
Email:
Age Group (choose one): □ UNDER 18 □ 18 To 59 □ 60 And Over
Primary Language:
Do require a translator? □ Yes □ No
If so, are you able to provide one? □ Yes □ No
□ Check box if you prefer to submit this complaint anonymously or it is a whistleblower
complaint.
Facebook: /NVAttorneyGeneral Twitter: @NevadaAG YouTube: NevadaAG
Page 2 of 5
SECTION 2: TYPE OF COMPLAINT (choose one)
□ Consumer/Financial Fraud (Scam)
□ Open Meeting Law
□ High Tech Crime
□ Opioid Crimes
□ Human Trafficking
□ Public Integrity
□ Insurance Fraud
□ Ticket Sales / Ticket Resellers
□
Medicaid Fraud
□
Workers Comp Fraud
□ Missing Children
□ Other ____________________
(please indicate topic)
□ Mortgage Fraud
SECTION 3: MY COMPLAINT IS AGAINST
(Do not re-enter your contact information in this section. Leave this section blank if
information is unknown or if not filing a complaint against a specific individual, business, or
agency.)
COMPLAINT AGAINST:
□
INDIVIDUAL
□
BUSINESS
□
AGENCY
Name of Individual:
Name of Business or Agency:
Contact at Business or Agency:
Additional Contact, If Applicable:
Street Address:
City: State: Zip Code:
Telephone Number: Other:
Email: Website:
Date Alleged Violation Occurred:
Was a Contract Signed?
□
YES
□
NO
If So, Provide Date:
Have You Contacted Another Agency for Assistance?
□
YES
□
NO
If So, Which Agency:
Have You Hired an Attorney?
□
YES
□
NO
If So, Provide Attorney’s Name and Contact Information:
Is a Court Action Pending?
□
YES
□
NO
Did You Make Any Payments to the Individual or Business?
□
YES
□
NO
How Much Were You Asked to Pay?
How Much Did You Actually Pay?
Date of Payment: Payment Method:
Facebook: /NVAttorneyGeneral Twitter: @NevadaAG YouTube: NevadaAG
Page 3 of 5
SECTION 4: DESCRIBE YOUR COMPLAINT:
Description of complaint is limited to the space provided below. Please be as accurate
and concise as possible. The Attorney General’s office may contact you if additional
information is needed.
Facebook: /NVAttorneyGeneral Twitter: @NevadaAG YouTube: NevadaAG
Page 4 of 5
SECTION 5: EVIDENCE
Describe and attach photocopies of any relevant documents, agreements, correspondence, or
receipts that support your complaint. Copy both sides of any canceled checks that pertain to
this complaint.
SECTION 6: WITNESSES
List any known witnesses or victims. Please provide names with addresses, phone numbers,
email addresses, and/or social or website information.
SECTION 7: SIGN AND DATE THIS FORM
(The Attorney General’s Office will not process any unsigned,
incomplete or illegible complaint forms)
I understand that the Attorney General is not my private attorney but strives to protect the public in part
through enforcement of laws prohibiting fraudulent, deceptive, or unfair business practices. I understand
that the Attorney General is prohibited by law from representing private citizens and does not seek
refunds or other legal remedies on their behalf. I am filing this complaint to notify the Attorney General’s
Office of the activities of a particular business, public body or individual. I understan
d that the
information obtained in this complaint may be used to establish violations of Nevada law in both private
and public enforcement actions and I agree to cooperate as a witness if required to do so. I understand
that in order to assist in resolution of my complaint, the Attorney General may need to send a copy of
this complaint form and any supporting documentation or correspondence to the business, public body,
or individual about whom I am complaining, or another federal, state, or local agency, and I authorize
this dissemination. I understand that if this complaint may be treated as a public record under Nevada’s
Open Meeting Law, and as such, it may be provided to the public upon request.
I certify under penalty of perjury that the information provided on this form is true and correct to the best
of my knowledge.
****ONLY COMPLAINTS THAT ARE SIGNED WILL BE PROCESSED****
SIGNATURE:
PRINT NAME:
DATE:
click to sign
signature
click to edit
Facebook: /NVAttorneyGeneral Twitter: @NevadaAG YouTube: NevadaAG
Page 5 of 5
SECTION 8: OPTIONAL INFORMATION
GENDER:
□
MALE
□
FEMALE
□
OTHER
ETNICITY (choose one):
□
White/Caucasian
□
Native American / Alaskan
□
Black/African American
□
Asian / Pacific Islander
□
Hispanic / Latino
□
Other
HOW DID YOU HEAR ABOUT OUR COMPLAINT FORM (choose one):
□
Contacted our Carson City Office
□
AG Website
□
Contacted our Las Vegas Office
□
AG Social Media Site
□
Contacted our Reno Office
□
Attended an AG Presentation
□
Nevada or Elected Official
□
Other
MARK ALL THAT APPLY:
Income Below Poverty Level
□
Military Service Member
Disaster Victim
□
Immediate Family of Service Member/Vet
Person with Disability
□
Veteran
Medicaid Recipient
□
Other
ADDITIONAL COMMENTS:
What are you hoping the Attorney General’s Office can do for you?
THANK YOU FOR SUBMITTING A COMPLAINT TO THE NEVADA ATTORNEY
GENERAL'S OFFICE. YOU WILL BE CONTACTED BY A MEMBER OF OUR STAFF
IF ADDITIONAL INFORMATION IS NEEDED FROM YOU.
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COMPLAINT FORM STATE OF NEVADA OFFICE OF THE (State of Nevada, Department of Information Technology)

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Completed 12 March 2021

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