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STATE OF NEVADA OFFICE OF THE ATTORNEY GENERAL (State of Nevada, Department of Information Technology)

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Page1of6
STATE OF NEVADA
OFFICE OF THE ATTORNEY GENERAL
100N.CARSONST.,CARSONCITY,NV89701–TEL#775‐684‐1100–FAX#775‐684‐1108
555E.WASHINGTONAVE.,STE3900,LASVEGAS,NV89101–TEL#702‐486‐3420–FAX#702‐486‐3768
COMPLAINT FORM
Theinformationyouprovideonthisformmaybeusedtohelpusinvestigateviolationsofstate
laws. Pleasebesuretocompleteallrequiredfields. Thelengthofthisprocesscanvary
dependingonthecircumstancesandinformationyouprovide. TheAttorneyGeneral’soffice
maycontactyouifadditionalinformationisneeded. Supplementalmaterialscanbeattached
toSection6ofthiscomplaintform,andifadditionalsupplementalmaterialsareacquiredafter
submittingthisform,pleaseemailthemtoAGCOMPLAINT@ag.nv.govwithCOMPLAINTinthe
subjectline.
***ONLYCOMPLAINTSTHATARESIGNEDWILLBEPROCESSED***
HAVE
YOUPREVIOUSLYFILEDACOMPLAINTWITHOUROFFICE?
YES
NO
Ifso,whataretheapproximatedatesofpreviouslyfiledcomplaint(s)?
SECTION1: COMPLAINANTINFORMATION
LASTNAME: FIRSTNAME: M.I.
ORGANIZATION:
ADDRESS: CITY: STATE: ZIP:
PHONE/MOBILE: EMAIL:
AGEGROUP UNDER21 21‐39 40‐65 OVER65
PRIMARYLANGUAGE:
SECTION2: TYPEOFCOMPLAINT
GENERALINVESTIGATIONS OPEN MEETING LAW
HIGHTECHCRIME PUBLIC INTEGRITY
INSURANCEFRAUD WORKERS COMP FRAUD
MEDICAIDFRAUD TICKET SALES
MORTGAGEFRAUD OTHER
Page2of6
SECTION3: MYCOMPLAINTISAGAINST
INDIVIDUALBUSINESS/GOVERNMENTAGENCY/REPRESENTATIVE
NAMEOFPERSON/BUSINESS/AGENCY:
ADDRESS:
CITY: STATE:
TELEPHONENUMBER: EMAIL:
WEBSITE:
DATEALLEGEDVIOLATIONOCCURRED:
WASACONTRACTSIGNED?YESNO
HAVEYOUCONTACTEDANOTHERAGENCYFORASSISTANCE?YESNO
IFSO,WHICHAGENCY:
HAVEYOUCONTACTEDANATTORNEY?YESNO
IFSO,PROVIDEATTORNEY’SCONTACTINFORMATION:
ISCOURTACTIONPENDING?YESNO
DIDYOUMAKEANYPAYMENTSTOTHEINDIVIDUALORBUSINESS?YESNO
HOWMUCHWEREYOUASKEDTOPAY? HOWMUCHDIDYOUACTUALLYPAY?
DATEOFPAYMENT: PAYMENTMETHOD:
F
acebook: /NVAttorneyGeneralTwitter: @NevadaAGYouTube: NevadaAG
Page3of6
SECTION4:DESCRIBEYOURCOMPLAINT:
EMAILAGCOMPLAINT@ag.nv.govtosubmitanyadditionalinformation
test
Page4of6
SECTION5: EVIDENCE
SECTION6: WITNESSES
SECTION7: SIGNANDDATETHISFORM
Facebook: /NVAttorneyGeneralTwitter: @NevadaAGYouTube: NevadaAG
(TheAttorneyGeneral’sOfficewillnotprocessany unsigned, incomplete or illegible complaint forms)
I understand that the Attorney General is not
my private attorney, but rather represents the public by enforcing laws
prohibiting fraudulent, deceptive or unfair business practices. I understand that the Attorney General does not
represent private citizens seeking refunds or other legal remedies. I am filing this complaint to notify the Attorney
General’s Office of the activities of a particular business or individual. I understand that the information contained in
this complaint may be used to establish violations of Nevada law in both private and public enforcement actions. In
order to resolve your complaint, we may send a copy of this form to the person or firm about whom you are
complaining. I authorize the Attorney General’s Office to send my complaint and supporting documents to the
individual or business identified in this complaint. I also understand that the Attorney General may need to refer my
complaint to a more appropriate agency.
I certif
y
unde
r
penalt
y
of perjur
y
that the information provided on this form is true and correc
to the best of my
knowledge.
****
ONLY COMPLAINTS THAT ARE SIGNED WILL BE PROCESSED****
SIGNATURE:
PRINTNAME:
DATE:
Listanyotherknownwitnessesorvictims. Pleaseprovidenames,addresses,phonenumbers,
emailaddressandwebsiteinformation.
Listandattachphotocopiesofanyrelevantdocuments,agreements,correspondenceor
receiptsthatsupportyourcomplaint. Copybothsidesofanycanceledchecksthatpertainto
thiscomplaint.
Page5of6
SECTION8:OPTIONAL INFORMATION
GENDER: MALE FEMALE
OTHER
ETHNICITY: WHITE/CAUCASIAN
BLACK/AFRICANAMERICAN HISPANIC/LATINO
NATIVEAMERICAN/ALASKANNATIVE ASIAN/PACIFICISLANDER OTHER
MAYWEPROVIDEYOURNAMEANDTELEPHONENUMBERTOTHEMEDIAINTHEEVENTOFAN
INQUIR
Y
ABOU
T
THISMATTER?
YES
NO
HOWDIDYOUHEARABOUTOURCOMPLAINTFORM(CHOOSEONE): Called/VisitedCarson
Cityoffice Called/VisitedLasVegasoffice Called/VisitedourRenooffice. Attendedan
AGPresentation/Event. AnotherNevadaStateAgency/ElectedOfficial. SearchEngine.
AGWebsite. AGSocialMediaSites.
Media/Newspaper/Radio/TV.
Other
MARKALLTHATAPPLY: Incomebelowfederalpovertyguideline. Disastervictim.
Personwithdisability. Medicaidrecipient. Militaryservicemember. Veteran.
Immediatefamilyo
f
servicemember/veteran.
Facebook: /NVAttorneyGeneralTwitter: @NevadaAGYouTube: NevadaAG
EMAILAGCOMPLAINT@ag.nv.govtosubmitanyadditionalinformation.
Page6of6
ADDITIONALCOMMENTS:WhatareyouhopingtheAttorneyGeneral’sofficecandofor
you?
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STATE OF NEVADA OFFICE OF THE ATTORNEY GENERAL (State of Nevada, Department of Information Technology)

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Completed 29 November 2020

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