Fillable MOTOR VEHICLE REPAIR CONSUMER COMPLAINT FORM (Florida Department of Agriculture and Consumer Services)

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MOTOR VEHICLE REPAIR CONSUMER COMPLAINT FORM (Florida Department of Agriculture and Consumer Services)

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The MOTOR VEHICLE REPAIR CONSUMER COMPLAINT FORM (Florida Department of Agriculture and Consumer Services) form is 2 pages long and contains:

  • 1 signature
  • 5 check-boxes
  • 28 other fields

Country of origin: US
File type: PDF

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Please return completed complaint form
to:
Florida Department of Agriculture and Consumer Services
FDACS
Division of Consumer Services
Mediation & Enforcement
2005 Apalachee Parkway
Tallahassee, Florida 32399-6500
MOTOR VEHICLE REPAIR
CONSUMER COMPLAINT FORM
www.FloridaConsumerHelp.com
NICOLE “NIKKI” FRIED
1-800-HELP-FLA (435-7352)
COMMISSIONER
(850) 410-3800
s. 570.544(4), Florida Statutes
Please complete this form in its entirety and provide as much information as possible. Only one business per complaint
form. Write legibly. (The information on this complaint form may be subject to public inspection pursuant to Chapter 119, F.S.)
Person Making Complaint:
Last Name, First Name, Middle Initial
Mailing Address
City, State, Zip Code, Country
Home and Business Phone, including Area Code
Email Address
Complaint is Against:
Name of Business
Mailing Address
City, State, Zip Code
Business Phone, including Area Code
Business Email and/or Web Address
Please check if you would like to receive our Florida Consumer E-Newsletter. Our newsletter provides monthly consumer tips and
information and is distributed by email.
Optional: Please select the box(es) that apply to you:
AGE 60 or older MILITARY STATUS Active Military Veteran
Have you retained an attorney? Yes No Have you filed suit in court? Yes No
If yes, you should rely on the advice of your attorney.
Year, make and type of vehicle involved:
Amount Paid: $
Refund or Restitution Amount You Are Requesting: $
Date of Repair: Specify repair:
(Example: Transmission/Engine/Brakes/Electrical/Collision/AC/Other)
Did you receive a copy of the written estimate before the work was performed? Yes No
Were the repairs the same ones you authorized? Yes No
Did you authorize any changes to the original estimate? Yes No
PLEASE ATTACH COPIES, DO NOT SEND ORIGINALS
• Documents and attachments submitted with this complaint may be subject to public inspection pursuant to Chapter
119, F.S.
FDACS-10903 Rev. 08/19
Page 1 of 2
• Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of
his official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in Section 775.082,
775.083, or 837.06, F.S.
Please explain your complaint. Attach additional sheets if necessary.
**What would satisfy your complaint?
**The department cannot require businesses to take a particular action such as repairing or replacing a product, or refunding money.
The department may act as a mediator to attempt dispute resolutions; however, on occasion, the only recourse is to seek legal remedy
through the court system.
My signature authorizes the Florida Department of Agriculture and Consumer Services to take any action deemed
necessary for purposes of mediation, investigation or enforcement. I understand that the department does not give legal
advice, and cannot take legal action for me. I am filing this complaint to notify the department of the activities of this
business/ individual and to seek any assistance available. I ACKNOWLEDGE THAT I AM AWARE THAT THE PERSON/
BUSINESS WHICH I AM COMPLAINING AGAINST WILL RECEIVE A COPY OF THIS COMPLAINT.
Signature: Date:
I am filing this complaint for information purposes only and DO NOT want mediation assistance.
FDACS-10903 Rev. 08/19
Page 2 of 2
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MOTOR VEHICLE REPAIR CONSUMER COMPLAINT FORM (Florida Department of Agriculture and Consumer Services)

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Completed 18 June 2021

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