Consumer Complaint Form | MSAGO Public Portal

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COMPLAINT FORM

Some information on this form may not apply to your complaint. Please complete the fields that are applicable to your situation.

Please provide as much information as possible about the matter.

* Denotes required fields

CONSUMER INFORMATION:

First Name*
Middle Name
Last Name*
Date Of Birth
Address*
City*
State*	Us State
Zip*
Cell/Home Phone*
Work Phone
Email

COMPANY INFORMATION: (Business filing complaint against)

Company Name*
Business Phone*
Address*
City*
State*	Us State
Zip*
Owner/Manager
Email Address

Name of Person you dealt with

Product or Service	Manufacturer

Make	Model (year/type/number)

Serial Number	Date of Purchase

Place of Purchase or service	Amount Paid

Amount Financed	Date of your last contact with business

With whom did you speak	Title

What was the response?

INCLUDE COPIES OF ALL CORRESPONDENCE WITH THIS COMPLAINT FORM

What other agencies have you contacted about this complaint?

Complete if Complaint is a Suspected Scam

How did you pay?

How much did you pay?

How were you contacted? (if via phone – provide the phone number, date, and time of the call)

When were you first contacted?

Summary of Complaint

Briefly describe your complaint. Include specific dates. Please remember a copy of this form may be provided to the business.

Attach COPIES of any relevant documents such as letters, bills of sale, contracts, warranties, advertisements, work orders, bills, etc. DO NOT SEND ORIGINALS TO THIS OFFICE.

____________________________________________________________________________________________________________

AFFIDAVIT

By signing this complaint, I consent for my name to be used by the Attorney General's Office in any subsequent legal action that is deemed necessary.

I hereby swear or affirm that the above statements are true and correct to the best of my knowledge.

*
Signature		Date

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