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Consumer Complaint Form

Please fill out ALL information. The fields with (*) asterisks by them are REQUIRED fields. Supporting documents can be attached after successful complaint submission.
 

Please select the subject area of your complaint*

Consumer Information
Name*


          First                    Middle                    Last  

Country*
Address*
City*
State/Province*    Zip*

Email*


Age
Military Status
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

Mode of Contact*  
Product or Service Involved
Cost of Product or Service
in US Dollars, e.g. 9426.38 		$

Did you sign a contract or any other similar documents?*

When   MM/DD/YYYY


Where
Are you currently represented by a lawyer? *
If so, you should rely on the advice of your lawyer.
Have you filed suit in court? *

Explain your complaint, describing the events in the order in which they occurred. *
 characters remaining of 1500

What would satisfy your complaint?

 characters remaining of 1000

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.

* 

Department of Agriculture and Consumers Services' Role
This complaint is submitted for:*  

The department cannot require businesses to take a particular action such as repairing or replacing a product or refunding money. The department may act as a mediator to attempt dispute resolutions; however, on occasion, the only recourse is to seek legal remedy through the court system.

*

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.

Date*  MM/DD/YYYY