CONSUMER COMPLAINT FORM
www.azag.gov
OFFICE OF THE ATTORNEY GENERAL
ATTORNEY GENERAL MARK BRNOVICH
1418357
YOUR NAME
YOUR ADDRESS
CITY STATE ZIP CODE
HOME PHONE NUMBER BEST NUMBER TO CALL DURING DAY
EMAIL ADDRESS
NAME OF FIRM YOU ARE COMPLAINING AGAINST
ADDRESS OF FIRM
CITY STATE ZIP CODE
PHONE NUMBER OF FIRM
For statistical purposes, please indicate:
Your Age: Military/veteran:
Under the age of 30 Between the age of 60-79 Currently in military service
Between the age of 31-59 Over the age of 80 A veteran
How did you hear about our complaint form (please choose only one):
Called Phoenix AG Office Visited an AG Satellite Office Another Arizona State Agency/State Legislator
Called Tucson AG Office An out of State Agency Attended AG Presentation/Event
Went onto AG Website Media: Newspaper/Radio/TV Other
May we send a copy of this to the person or firm you are complaining against? YES NO
(By selecting the answer, “Yes”, to the question, “May we send a copy of this to the person or business you are complaining against,” I hereby authorize the Office of the
Arizona Attorney General to communicate with the party(ies) against whom I have filed this complaint. I also authorize the party(ies) against whom I have filed this complaint
to communicate with and provide information related to my complaint, including disclosure of non-public personal information, to the Office of the Arizona Attorney General in
connection with this complaint. If your response is “No”, we may be prevented from taking any action on your complaint.)
May we provide your name and telephone number to the media in the event of an inquiry about this matter? YES NO
May we send a copy of your complaint to another government agency for their review or investigation? YES NO
Was an oral or written warranty given? YES NO
Did you sign any documents? YES NO
Date of transaction Place of transaction
Witness to transaction Salesperson’s name
Total amount of damages (list actual loss only)
Have you complained to the firm? YES NO
What was their response?
Was the product or service advertised? YES NO
If yes, indicate the date and how it was advertised
Do you have an attorney? YES NO
If yes, please provide the attorney’s name and address
Is any legal action pending? YES NO
List any other consumer agencies contacted
PLEASE EXPLAIN THE ENTIRE CIRCUMSTANCES SURROUNDING YOUR COMPLAINT IN THE FOLLOWING PAGE PROVIDED.
I declare, under penalty of perjury, that the facts and statements contained in this declaration, including any attached statements, are true, correct, and
based upon my personal knowledge:
Signature Date
click to sign
signature
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