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File a Complaint or Inquiry

Please complete each box. Once submitted, our compliance examiners will review your inquiry. If possible we will reply via email. However if your situation is complex or we have further questions, we will contact you by phone or mail.

Fields with a * are required fields.

Information About You

Courtesy Title

*Name

*Address

*City	*State	*ZIP

*I can be reached by phone between 8am and 4pm at:

*E-mail Address

Information About the Business in Question

*Business Type

*Business Name

*Business Address

*City	*State	*ZIP

*Name of person you dealt with

*Phone Number

Information About Your Situation

	A person came to my home
	I went to the place of business
	Away from the place of business (convention, at my job, etc.)
	I received a telephone call
	I received information in the mail
	I responded to a radio/TV ad
	I responded to a printed ad
	Business e-mailed information to me
	I contacted the business by Internet
	I responded to an Internet ad

Have you filed a complaint with any other agency?
Yes No

If yes:
When?	Which agency?

If your inquiry involves a debt, what type of debt is it? (Medical bill, Credit card, etc.)

*Briefly describe the nature of your concern and the events in the order they happened, including specific dates, and the activities or practices to which you object.

*What do you think would be a fair resolution to this matter?

Consent to Release Information - The information provided may be used in efforts to resolve my problem and may be shared with the party complained against. The Department may seek additional information from businesses and I authorize the disclosure of applicable documents to the Department, including those protected by laws such as HIPAA. I understand any information may be subject to open records laws.

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