Do not include personal or sensitive information such as health or medical history, date of birth, or
driver license, social security, financial account or credit/debit card numbers on this form.
After you submit this dispute form, the Attorney General’s Office may provide a copy of it and any other
information you provide to the company disputed against and/or to another agency.
PLEASE READ THE FOLLOWING CAREFULLY. By submitting this form, you are signifying that you have read and understand the following statements and conditions:
You can attach documents to your complaint to help us better understand your issue; any attachments need to be mailed to:
Do not include personal or sensitive information such as account numbers or social security numbers in any attachments.
I believe that the company I named in this dispute has committed unfair and deceptive business practices.
Depending on the nature of my dispute, the Attorney General’s Office may forward a copy of this form in its entirety, including any documents I provide to the company complained about and ask for a response or may refer the dispute to another agency.
The Attorney General's Office may keep a record of this form and any documents I provide and may provide copies of them to other private and public agencies. I authorize the Attorney General’s Office to give copies of the form and any documents I provide and any information in them to anyone deemed necessary by the Attorney General’s Office.
If I have a complaint about criminal conduct, such as fraud, the Attorney General’s Office recommends that I contact local law enforcement agencies, which have jurisdiction over criminal activity.
The information that I provide may be used to help the Attorney General’s Office detect patterns of unfair and deceptive trade practices, which may lead to investigations on behalf of the public to eliminate such practices. However, the Attorney General’s Office cannot act as my lawyer, a court of law, or legal advisor. The Attorney General's Office is not my personal legal representative and does not conduct litigation on behalf of individuals in matters involving private controversies. The Attorney General’s Office recommends that I consult a private attorney. I may lose my right to sue about this matter entirely if I wait too long to do so. Any action by the Attorney General's Office may not result in a refund or other relief for me personally. I am, however, filing this dispute to notify the Attorney General’s Office of the activities of the named party and to seek any assistance the Attorney General’s Office may be able to render.
The information given is true to the best of my knowledge and belief.