Please enter the case number (if you have one)

 
 
Case

Online Consumer Complaint Form

To prevent delay, please answer all of the following questions. DO NOT include your Social Security Number on this form or any accompanying documents. At the end of this form, you may upload any signed contracts, written agreements, or other supporting documents related to this complaint.
  = Required Information

1. Your Information

2. Who is your complaint against?

3. The date(s) on which you entered into this transaction:

4. Where did transaction take place?

5. First contact between you and firm?

6. Do you consent to the Consumer Protection Division disclosing the following information to the public? (answers are required)

Yes  No

7. What was this transaction for?

8. How did you pay?

9. Have you complained to the business?

10. Have you already filed a complaint with another agency?

11. Have you contacted a private attorney?

12. Have you started court action?

13. Have you been sued over this issue?

14. Dollar amount associated with your loss, if any.

15. Please describe complaint in Detail?

16. How would you like complaint resolved?

17. What will happen now? What else should you do?

The Consumer Protection Division will send a copy of your complaint to the respondent firm or licensed professional.

This office cannot disclose your complaint against a licensed professional to the public unless this office files a disciplinary action against the licensed professional. This office cannot disclose your complaint against any other person or firm without your consent.

This office represents the State of Indiana and is strictly limited in what remedies it can pursue. You may be entitled to compensation or other rights that we cannot pursue for you. In addition to filing this complaint, you should contact a private attorney or a small claims court.

18. Consent and Verification

I affirm, under the penalties for perjury, that the foregoing representations are true. I consent to the Consumer Protection Division obtaining or releasing any information in furtherance of the disposition of this complaint. I consent to the release of information included in this complaint to other public agencies attempting to discover ongoing fraudulent patterns or practices and for the purpose of law enforcement. I understand that I should not include my Social Security Number in any information submitted to the Consumer Protection Division. If I do provide my Social Security Number, I expressly consent to the disclosure of my Social Security Number in accordance with Indiana Code § 4-1-10-5(2).
4/18/2014 ]

19. Consent to correspondence by Email

Do you consent to the Consumer Protection Division sending you correspondence related to this complaint to your email address? If yes, you will not be mailed such correspondence via the U.S. Postal Service. If you select Yes please enter the email address we should use to send correspondence even if it is the same as the email address you entered earlier.
 
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