Consumer Complaint Form

Please fill out ALL information. Incomplete forms CANNOT be processed. DO NOT use this complaint form for Do Not Call complaints.

The fields with (*) asterisks by them are REQUIRED fields. Our system will not process this form without the REQUIRED fields.

Please select the subject area of your complaint*

Consumer Information
Name*	Last First Middle
Country*
Address*
City*
State/Province*	Zip
Email*	I would like to subscribe to the Florida Consumer E-Newsletter
Age Group*	Some age groups may receive special protection under Florida law.
Home Phone*	(XXX-XXX-XXXX)
Work/Cell Phone	(XXX-XXX-XXXX)

Business Information (Complaint Filing Against)
Name*
Address*
City*
State/Province*	Zip
Phone*	(XXX-XXX-XXXX)

Product Information
Date of Purchase (MM/DD/YYYY)
Contacted by*	TelephoneMailOther
Product or Service Involved
Cost of Product or Service($)
Did you sign a contract or any other similar documents?* YesNo		When (MM/DD/YYYY) Where
Are you currently represented by a lawyer? * If so, you should rely on the advice of your lawyer.		YesNo
Have you filed suit in court? *		YesNo
Explain your complaint, describing the events in the order in which they occurred. *
What would satisfy your complaint?

Authorization
I doI do not * authorize you to send a copy of my complaint to the business I am complaining about or to any other government agency necessary for purposes of mediation, investigation or enforcement." I acknowledge that I am aware that all information I provide with my complaint, except credit card numbers, is a matter of public record and is not considered confidential.

Authorization

I doI do not *
authorize you to send a copy of my complaint to the business I am complaining about or to any other government agency necessary for purposes of mediation, investigation or enforcement."

I acknowledge that I am aware that all information I provide with my complaint, except credit card numbers, is a matter of public record and is not considered confidential.

False Official Statements
Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082, s.775.083, or s. 775.084, Florida Statutes. I have read and understand this statement*

False Official Statements

Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082, s.775.083, or s. 775.084, Florida Statutes.

I have read and understand this statement*

Department of Agriculture and Consumers Services' Role
I understand that your office does not give legal advice. I also understand that your office cannot take legal action for me. I am filing this complaint to notify your office of the activities of this business/individual and to seek any assistance you may be able to render. I have read and understand this statement*

Department of Agriculture and Consumers Services' Role

I understand that your office does not give legal advice. I also understand that your office cannot take legal action for me. I am filing this complaint to notify your office of the activities of this business/individual and to seek any assistance you may be able to render.

I have read and understand this statement*

Certification
By choosing to submit this form electronically, I certify and agree that by entering my name in the space below, I bind and legally obligate myself to the same extent as I would by signing my name on a printed paper version of this form.
Signature*	Date (MM/DD/YYYY)*