Office Use Only
If you paid with a credit card, have you contacted your credit card company to register
Illinois Attorney General
Consumer Fraud Bureau
500 South Second Street
Springfield, IL 62701
1-800-243-0618 (Toll free in IL)
Fill out the form online, then print and mail to the address above. Include copies (no originals please) of any supporting documents.
NAME OF SELLER OR PROVIDER OF SERVICE:
Your Telephone Number:
Are you a senior citizen?
Additional seller or provider of service involved in transaction:
Has this matter been submitted to another government agency, an arbitration service, or to any attorney?
If yes, please give name, address, telephone:
Is court action pending?
INFORMATION ABOUT THE TRANSACTION
Date of Transaction:
Did you sign a contract?
(If yes, please attach a copy)
Date contract was signed:
(Please attach a copy of the advertisement, if applicable.)
Was the product or service advertised?
How was the service advertised?
Direct mail solicitation
Yellow pages of the telephone book
Display at merchant's place of business
Display at a trade show/convention, etc.
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
(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.
Your e-mail address (optional):
Are you a veteran?
Are you a service member?