Office Use Only
CLMS:
AG:
If you paid with a credit card, have you contacted your credit card company to register
a dispute?
KWAME RAOUL
Illinois Attorney General
Consumer Fraud Bureau
500 South Second Street
Springfield, IL 62701
217-782-1090
1-800-243-0618 (Toll free in IL)
TTY: 1-877-844-5461
Fill out the form online, then print and mail to the address above. Include copies (no originals please) of any supporting documents.
YOUR INFORMATION:
NAME OF SELLER OR PROVIDER OF SERVICE:
www.IllinoisAttorneyGeneral.gov
Address:
City:
State:
Zip Code:
County:
Name:
Address:
City: State:
Zip Code:
Your Telephone Number:
Daytime:
Are you a senior citizen?
Yes No
Additional seller or provider of service involved in transaction:
Name:
Address:
City:
State:
Zip Code:
Has this matter been submitted to another government agency, an arbitration service, or to any attorney?
NoYes
If yes, please give name, address, telephone:
Is court action pending?
NoYes
INFORMATION ABOUT THE TRANSACTION
Date of Transaction:
Did you sign a contract?
(If yes, please attach a copy)
NoYes
Date contract was signed:
When?
(Please attach a copy of the advertisement, if applicable.)
NoYes
Was the product or service advertised?
How was the service advertised?
Newspaper/magazine
Radio advertisement
Television advertisement
Internet advertisement
E-mail solicitation
Direct mail solicitation
Telephone solicitation
Yellow pages of the telephone book
Facsimile solicitation
Door-to-door solicitation
Display at merchant's place of business
Display at a trade show/convention, etc.
Other
Total Cost of product/service:
Amount paid to date/down payment:
Cash Check Money Order Credit Card Debit Card Bank Draft
Wire Transfer Automatic Debit
Other
NoYes
(Under the Federal Fair Credit Billing Act, you have 60 days from the time that you receive
your statement to dispute the charge.)
Method of payment (check one) (Please attach a copy.)
Mr. Mrs. Ms.
Name:
(check one)
Ext.:
Website:
Website:
Your e-mail address (optional):
-
-
-
Ext.:
-
Evening:
Ext.:
-
-
Telephone:
Ext.:
-
-
Telephone:
Are you a veteran?
Yes No
Are you a service member?
Yes No
