Fillable Division of Consumer Services CONSUMER COMPLAINT FORM Florida

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Division of Consumer Services CONSUMER COMPLAINT FORM Florida

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Florida Department of Agriculture and Consumer Services
Division of Consumer Services
CONSUMER COMPLAINT FORM
Section 570.544(4), Florida Statutes
NICOLE “NIKKI” FRIED
COMMISSIONER
Please return completed complaint
form to:
FDACS
Mediation & Enforcement
2005 Apalachee Parkway
Tallahassee, Florida 32399-6500
www.FloridaConsumerHelp.com
1-800-HELP-FLA (435-7352)
(850) 410-3800
Please complete this form in its entirety and provide as much information as possible. Only one business per complaint
form. Write legibly. (The information on this complaint form may be subject to public inspection pursuant to Chapter 119, F.S.)
Person Making Complaint:
Last Name, First Name, Middle Initial
Mailing Address
City, State, Zip Code and Country
Home and Business Phone, including Area Code
Email Address
Complaint is Against:
Name of Business
Mailing Address
City, State, Zip Code
Business Phone, including Area Code
Business Email and/or Web Address
Please check if you would like to receive our Florida Consumer E-Newsletter. Our newsletter provides monthly consumer
tips and information and is distributed by email.
Optional: Please select the box(es) that apply to you:
AGE 60 or older MILITARY STATUS Active Military Veteran
Product or Service involved:
Amount Paid:
$
Refund or Restitution Amount You Are Requesting: $
Date of Transaction:
I was contacted by:
Telephone
Mail
Other
Have you retained an attorney? Yes No Have you filed suit in court? Yes No
If yes, you should rely on the advice of your attorney.
Did you sign a contract or other papers, i.e. estimates, invoices, or other supporting documents? Yes No
PLEASE ATTACH COPIES, DO NOT SEND ORIGINALS.
• Documents and attachments submitted with this complaint may be subject to public inspection pursuant to Chapter 119, F.S.
• Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his
official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in Section 775.082, 775.083, or
837.06, F.S.
FDACS–10000 Rev. 06/19
Page 1 of 2
Please explain your complaint. Attach additional sheets if necessary.
** What would satisfy your complaint?
**The department cannot require businesses to take a particular action such as repairing or replacing a product or refunding money. The
department may act as a mediator to attempt dispute resolutions; however, on occasion, the only recourse is to seek legal remedy through
the court system.
My signature authorizes the Department of Agriculture and Consumer Services to take any action deemed necessary
for purposes of mediation, investigation or enforcement. I understand that the department does not give legal advice
and cannot take legal action for me. I am filing this complaint to notify the department of the activities of this business/
individual and to seek any assistance available. I ACKNOWLEDGE THAT I AM AWARE THAT THE PERSON/ BUSINESS
WHICH I AM COMPLAINING AGAINST WILL RECEIVE A COPY OF THIS COMPLAINT.
Signature:
Date:
I am filing this complaint for information purposes only and DO NOT want mediation assistance.
FDACS–10000 Rev. 06/19
Page 2 of 2
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Division of Consumer Services CONSUMER COMPLAINT FORM Florida

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Completed 8 February 2021

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