Fillable KWAME RAOUL Springfield, Illinois 62701 500 South Second (Illinois Attorney General)

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KWAME RAOUL Springfield, Illinois 62701 500 South Second (Illinois Attorney General)

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KWAME RAOUL
Illinois Attorney General
Consumer Fraud Bureau
500 South Second Street
Springfield, Illinois 62701
217-782-1090 • 1-800-243-0618 (Toll free in Illinois) • TTY : 1-877-844-5461
www.IllinoisAttorneyGeneral.gov
YOUR INFORMATION:
Check
One:
Are you a: Senior Citizen?
NAME OF SELLER OR PROVIDER OF SERVICE:
Additional seller or provider of service involved in transaction:
Has this matter been submitted to another government agency, an arbitration
service, or an attorney?
If yes, please give name, address, telephone number.
Is court action pending?
Office Use Only
PAGE 1
Address:
City: State: Zip:
County:
Your e-mail address (optional):
Who referred you to this office?
Name:
Address:
City: State:
Zip:
Web site:
Mr. Mrs. Ms.
Yes No
Web site:
City:
Address:
Name:
NoYes
NoYes
AG:
CLMS:
Zip:State:
Your telephone number(s): Daytime:
Evening:
Telephone:
Telephone:
Name:
(Last, First)
Rev. 4/1/16 (lfs)
NoYesVeteran?
No
YesService Member?
(000) 000-0000
(000) 000-0000
(000) 000-0000
(000) 000-0000
PAGE 2
INFORMATION ABOUT THE TRANSACTION:
Did you sign a contract?
(Please attach a copy.)
Was the product or service advertised?
(Please attach a copy of the advertisement, if available.)
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 (please specify)
Method of payment (check one): (Please attach a copy.)
Cash Check Money Order
Credit Card Debit Card Bank Draft
Wire Transfer Automatic Debit Other (please specify):
(Under the Federal Fair Credit Billing Act, you have 60 days from the time that you receive your
statement to dispute the charge.)
If yes, when?
Total cost of product/service: $
Amount paid to date/down payment: $
NoYes
NoYes
If you paid with a credit card, have you contacted your credit card company to register a
dispute?
NoYes
Date of transaction?
If yes, date contract was signed:
Rev. 4/1/16 (lfs)
Where did the transaction take place?
At my home
Over the telephone
By mail
Over the Internet
Trade show/convention/home show
At the firm’s place of business
By facsimile
Other (please specify)
There was no transaction
Have you complained to the company or individual?
If yes, provide name and phone number of the individual(s):
FOR COMPLAINTS REGARDING MOTOR VEHICLES:
New:
Yes No
As-Is:
Yes No
Warranty:
PAGE 3
Make:
Model:
Year:
Current mileage:
Mileage at purchase:
Name of extended warranty:
NoYes
NoYes
If yes, expiration date:
Purchase date:
Rev. 4/1/16 (lfs)
Briefly describe the transaction and your complaint.
You may use additional sheets if necessary.
Please attach copies of all contracts, letters, receipts, cancelled checks (front and
back), advertisements, or any other documents that relate to your complaint.
PLEASE DO NOT SEND ORIGINALS.
READ THE FOLLOWING BEFORE SIGNING BELOW:
In filing this complaint, I understand that the Attorney General is not my private attorney,
but rather enforces laws designed to protect the public from misleading or unlawful
practices. I also understand that if I have any questions concerning my legal rights or
responsibilities, I should contact a private attorney. I have no objection to the contents of
this complaint being forwarded to the business or the person the complaint is directed
against, unless the box below is checked.
By filing this complaint, I hereby give the business complained about my consent to
communicate, including disclosure of non-public personal information, with the Office of
the Attorney General about any and all matters connected with this complaint.
Please print and send the completed form to the address at the top of this complaint form.
What form of relief are you seeking? (E.g., exchange, repair, money back, product
delivery, etc.)
Date:
Please do not send this complaint to the business complained about.
Signature:
Rev. 1/17/19(sd)
PAGE 4
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KWAME RAOUL Springfield, Illinois 62701 500 South Second (Illinois Attorney General)

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Completed 13 August 2020

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