OMB# 3084-0047

The estimated average amount of time to complete the form is 5 minutes.

Complaint Form

Before completing this form, please read our Privacy Policy and you need to know before filing a complaint if you have not already done.

You do not need to complete every field. However, 3 fields are required - these are marked with a *. The more information you provide, the more useful your complaint will be.

1. Your Contact Information

First/given name:
If you do not provide your name or other information, it may be impossible for us to refer, respond to, or investigate your complaint.
Last/family name:
Street address:
Address Line 2:
City/Town:
Country:*
State/Province:
Other State/Province (not listed):
Your e-mail address is required if you would like us to send you a reference number for your complaint. The reference number will make it possible for you to access your complaint later.
Zip/Post Code:
E-mail Address:

Home phone

Country code:
City/area code:
Phone Number:

Work phone

Country code:
City/area code:
Phone Number:
Ext:

2. Your Complaint

About The Company

Name of company:

Website:
Reminder:
You are NOT REQUIRED to fill out every item. Just provide as much information as you can.
Email Address:
Street Address:
Address Line 2:
City/Town:
Country:
State/Province:
Other State/Province (not listed):
Zip/Post Code:

Company Contact Person

First/given name:
Last/family name:

Company Phone

Country code:
City/area code:
Phone Number:
 
Ext:

About This Transaction

Type of Transaction:*
 
Problem Encountered:*
 
How Company First Contacted You:
Hold down the ctrl-key to select more than one. (or the cmd-key on a mac)
Date Company First Contacted You:

MM/DD/YYYY

Amount Company Asked You to Pay

Amount:
Please provide the amount rounded to a whole number, with no special characters such as [,] [.] [£] [$] , etc.
Currency:

Amount You Actually Paid

Amount:
Currency:
Method of Payment:
 
 

3. Additional Comments


PLEASE DO NOT INCLUDE SENSITIVE PERSONAL INFORMATION (e.g., Social Security number, date of birth, financial account or credit/debit card numbers, driver's license number, detailed health or medical history, or similarly sensitive information).

Please limit entry to 45 lines.

By clicking on the submit button below, you agree to have your complaint data included in a multi-national government database.




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Providing information using this form is voluntary. Under the Paperwork Reduction Act, as amended, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.


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