Office Use Only
CLMS:
AG:
If you paid with a credit card, have you contacted your credit card company to register
a dispute?
LISA MADIGAN
Illinois Attorney General
Consumer Fraud Bureau
500 South Second Street
Springfield, IL 62701
217-782-1090
1-800-243-0618 (Toll free in IL)
TTY: 1-877-844-5461
Fill out the form online, then print and mail to the address above. Include copies (no originals please) of any supporting documents.
YOUR INFORMATION:
NAME OF SELLER OR PROVIDER OF SERVICE:
www.IllinoisAttorneyGeneral.gov
Address:
City:
State:
Zip Code:
County:
Name:
Address:
City: State:
Zip Code:
Your Telephone Number:
Daytime:
Are you a senior citizen?
Yes No
Additional seller or provider of service involved in transaction:
Name:
Address:
City:
State:
Zip Code:
Has this matter been submitted to another government agency, an arbitration service, or to any attorney?
NoYes
If yes, please give name, address, telephone:
Is court action pending?
NoYes
INFORMATION ABOUT THE TRANSACTION
Date of Transaction:
Did you sign a contract?
(If yes, please attach a copy)
NoYes
Date contract was signed:
When?
(Please attach a copy of the advertisement, if applicable.)
NoYes
Was the product or service advertised?
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
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
Other
NoYes
(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.
Name:
(check one)
Ext.:
Website:
Website:
Your e-mail address (optional):
-
-
-
Ext.:
-
Evening:
Ext.:
-
-
Telephone:
Ext.:
-
-
Telephone:
Are you a veteran?
Yes No
Are you a service member?
Yes No
$0.00
$0.00
FOR COMPLAINTS REGARDING MOTOR VEHICLES, PLEASE COMPLETE THIS BOX:
There was no transaction
By facsimile
At the firm's place of business
Trade show/convention/home show
Over the Internet
By mail
Over the telephone
At my home
Other (Please specify)
Have you complained to the company or individual?
NoYes
If yes, provide name and phone number of the individual(s):
Make:
Model:
Year:
New:
No
Yes
As-Is:
Yes
No
NoYes
Warranty:
Mileage at Purchase:
Name of Extended Warranty:
Current Mileage:
Purchase Date:
Expiration Date:
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.
What form of relief are you seeking? (E.g., exchange, repair, money back, product delivery, etc.)
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.
Signature:
Please print and send the completed form to the address at the top of this complaint form.
Please do not send this complaint to the business complained about.
Date:
Where did the transaction take place?
Rev. 4/1/2016 (lfs)
Print Form
Reset Form
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome