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Consumer Dispute Form
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Dispute Date: 10/21/2014
Your Information
  Are you over the Age of 60?
Your Full Name:
Mailing Address:
City,State/Zip:
Telephone: or 
Incident Address:
City,State/Zip:
Parish:
Company Information
  Person Complained Against:
Company Name:
Address:
City,State/Zip:
Telephone:
Complaint Information
  Date of Transaction:
Date Contacted Company:
Description:
Manufacturer:
Purchase:
AFTER REVIEWING YOUR DISPUTE AND THE STEPS YOU HAVE TAKEN TO RESOLVE IT, YOU MAY BE REFERRED TO ANOTHER AGENCY, A PRIVATE ATTORNEY, SMALL CLAIMS COURT OR JUSTICE OF THE PEACE COURT, OR SOME OTHER METHOD OF RESOLVING YOUR DISPUTE. A COPY OF THIS DISPUTE MAY BE SENT TO THE BUSINESS COMPLAINED AGAINST.
  Full Dispute:
What would Satisfy your Dispute?

PLEASE READ THE FOLLOWING CAREFULLY. By submitting this form, you are signifying that you have read and understand the following statements:

Any and all attachments need to be mailed to:
PO Box 94005,
Baton Rouge, LA 70804
I understand the Attorney General's Office may provide copies of this form and any attachments to the business complained about and other private and public agencies. I authorize the Office of the Attorney General to give copies or any information of the form to anyone deemed necessary by them.

I understand that the Attorney General's office is not my legal representative. I understand that it is recommended that I consult a private attorney. I also understand that I may lose my private right to sue about this matter entirely if I wait too long to do so. I also understand that any action by the Attorney General's office may not result in a refund or other relief for me personally.

I wish to file this dispute with the Attorney General's office. I understand that your office does not conduct litigation for individuals in matters which involve purely private controversies. I am, however, filing this dispute to notify your office of the activities of this party and to seek any other assistance you may be able to render.


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