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  = Required Information

What is your Complaint Regarding

Your Information

May we contact you by email? If yes, we will not contact you by regular mail.

Additional Comments

Consent and Verification

Do you consent to disclosing the following information to the public?
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).
12/13/2019 ]
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