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Motor Vehicle Repair Consumer Complaint Form - Division of Consumer Services, FDACS

Motor Vehicle Repair Consumer Complaint Form
Chapter 570.544(4) F.S.

Please fill in all information. Incomplete forms cannot be processed. Fields with the red asterisk (*) are required fields. Once this form has been completed and submitted, a copy of your complaint will be displayed for printing and record keeping purposes

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)
Business Name*

Contact Person
Address*
City*
State/Province*      Zip   
Phone*   XXX-XXX-XXXX     

Vehicle Information
Make*

Model*

Year*

Motor Vehicle Repair Information
Date of Repair*   MM/DD/YYYY
Repair Type*
Did you receive a copy of the written estimate before the work was performed? *
Were the repairs the same ones you authorized? *
Did you authorize any changes to the original estimate? *
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