Motor Carrier Division
555 Wright Way
Carson City, Nevada 89711
(775) 684-4711
www.dmvnv.com
COMPLAINT
VOLUNTARY STATEMENT
Case No. _______________ File Date ______________
I wish to file a complaint against the business or individual named below. I understand that the Department of Motor Vehicles DOES
NOT represent private citizens seeking return of monies or other personal remedies as a result of contractual disputes or civil actions.
Person Filing Complaint:
Name _______________________________________________________Day Time Phone ______________________
Address _____________________________________________________Home Phone _________________________
City _______________________________________________________________State ____________Zip __________
Business or Individual Complaint Filed Against: Business License No _____________________
(If applicable)
Business Name ____________________________________________Phone __________________________________
Address__________________________________________________________________________________________
City _______________________________________________________________State ____________Zip __________
Representative’s Name _____________________________________________________________________________
Vehicle Involved:
(If applicable)
VIN |____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
Year _______________Make _______________________Model ____________________Color ___________________
Other complaint not involving a motor vehicle sale or repair.
Explain Complaint: (Please attach copies of any documents you have to support your complaint.)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
I, _______________________________________________ freely and voluntarily give this affidavit to the State of Nevada,
Department of Motor Vehicles. I further certify and affirm that all information is true and correct to the best of my knowledge and that I
will testify to these facts if requested to do so in any action brought against the business or individual named above.
Signatures must be original. Photocopies are not acceptable.
___________________________________________________ ________________________________
Signature of Complainant Date
___________________________________________________ ________________________________
Signature of Notary or Authorized DMV Representative Date
MC-083 (12-2012)
