INSTRUCTIONS: To prevent delay, please be sure to complete both sides of this form in full. Please print clearly or type. Do not include your Social Security Number
on this form or in any accompanying documents. Please note: If you have already obtained a judgment, or there is pending litigation, we may be
limited or unable to take further action on your complaint.
Section 1: Your Information
Mr. Mrs. Ms. Dr. Miss Rev.
Street Address
Full Name or Organization/Agency
Zip Code
If an Organization/Agency provide a Primary Contact Name
Daytime Phone
Age Group
18-24 25-34 35-44 45-54 55-59 60+
Email Address
Section 2: Who is the Complaint Against?
Name of Individual/Representative you dealt with
Street Address
Zip Code
Daytime Phone
Email Address
Section 3: Transaction/Incident Details
3-A: Date of Transaction/Incident
3-B: If a Transaction, what was the Transaction for?
My business My family/household My farm Non-Profit/Church
3-C: Where did the Transaction/Incident occur? (check box where applicable)
My home By Internet/Email
At the location of the business By Telephone
Away from the location of the business (work, convention, etc.) By Social Media
By Mail Other ___________________________________________
3-D: What was the very first contact between you and the Individual/Business?
I telephoned the individual/business I received information in the mail I responded to a printed advertisement
I responded to a TV/radio ad I went to the location of the business Other, describe below:
A person came to my home I received a phone call from the business
I received information by email I responded to an offer on the internet ____________________________________
3-E: How did you Pay?
Cash Credit Card/Pre-Pay Medicaid Pay-Pal Wire Transfer
Check Installment Loan Medicare Private Insurance Other ___________________________
3-F: What, if any, is the Dollar amount associated with your loss?
Section 4 Actions Taken by Consumer
Yes No
4-A: Did you sign a written agreement or contract? If yes, please attach a copy of the documentation.
Yes No
4-B: Have you hired a private attorney?
Yes No
4-C: Have you started a court action? If yes, please attach a copy of all court papers.
Yes No
4-D: Have you sued, or have you been sued, over this incident/transaction? If yes, please attach a copy of all court papers.
Office of the Indiana Attorney General
(R5 / 12-17)
Page 2 of 2
Section 4 Actions Taken by Consumer - continued
Yes No
4-E: Have you complained to the Individual/Business?
Yes No
4-F: Have you filed a complaint with any other agency? If yes, list other agency:
Section 5 Transaction/Incident Details attach additional pages if necessary
Please remember to attach a copy of all documentation involved (order blank, warranty, credit card receipt and statement, invoice, contract or written agreement, advertisement, cancelled
check, correspondence etc). Please print clearly or type. Do Not Include your Social Security Number.
If you answered "Yes" to 4-E or 4-F above, please include those details also with your description of the Transaction/Incident.
Section 6 How would you like your Complaint resolved?
Section 8 Mail Completed Forms to:
The Consumer Protection Division will send a copy of your complaint to the
respondent individual/business or licensed professional. This office cannot disclose
your complaint against a licensed professional to the public unless this office files a
disciplinary action against the licensed professional. This office represents the State of
Indiana and is limited in the remedies it can pursue. You may be entitled to compensation
or other rights that we cannot pursue for you. In addition to filing this complaint, you may
want to consider contacting a private attorney or your local small claims court.
Office of the Indiana Attorney General
Consumer Protection Division
Government Center South, 5
302 W. Washington Street
Indianapolis, IN 46204
317-232-6330 (phone) 317-233-4393 (fax)
Section 9 Consent and Verification
Do you consent to disclosing the
following information to the public?
Yes No The nature of the complaint and the individual/business name
Yes No Your name
Yes No Your phone number
I affirm, under penalties for perjury, that the foregoing representations are true. I consent to the Consumer Protection Division obtaining or releasing
any information in furtherance of the disposition of this complaint. I consent to the release of information included in this complaint to other public
agencies attempting to discover ongoing fraudulent patterns or practices and for the purpose of law enforcement. I understand that I should not
include my Social Security Number in any information submitted to the Consumer Protection Division. If I do provide my Social Security Number, I
expressly consent to the disclosure of my Social Security Number in accordance with Indiana Code § 4-1-10-5(2).
Your signature