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.
Full Name or Organization/Agency
If an Organization/Agency provide a Primary Contact Name
18-24 25-34 35-44 45-54 55-59 60+
May we contact you by email? If yes, we will not contact you by regular mail Yes No
Are you or your spouse active military? Yes No
Section 2: Who is the Complaint Against?
Name of Individual/Representative you dealt with
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
4-A: Did you sign a written agreement or contract? If yes, please attach a copy of the documentation.
4-B: Have you hired a private attorney?
4-C: Have you started a court action? If yes, please attach a copy of all court papers.
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)