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Party or Firm You Are Complaining Against
May we send a copy of this to the person or business you are complaining against?
(By selecting the answer, “Yes", to the question, “May we send a copy of this to the person or business you are complaining against,” I hereby authorize the Office of the Arizona Attorney General to communicate with the party(ies) against whom I have filed this complaint. I also authorize the party(ies) against whom I have filed this complaint to communicate with and provide information related to my complaint, including disclosure of non-public personal information, to the Office of the Arizona Attorney General in connection with this complaint. If your response is "no", we may be prevented from taking any action on your complaint.)
Please explain the entire circumstances surrounding your complaint below:
Please fully describe any oral or written misrepresentations made to you.
Have you complained to the firm/agency/business?
Was an oral or written warranty given?
Did you sign any documents?
Date of Transaction:
Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Year 2010 2011 2012 2013 2014 2015
Witness to Transaction:
Was the product or service advertised?
If yes, indicate the date and how it was advertised:
Do you have an attorney?
If yes, please provide the attorney's name and address:
Is any legal action pending?
List any other consumer agencies contacted:
May we provide your name and telephone number to the media in the event of an inquiry about this matter?
May we send a copy of your complaint to another government agency for their review or investigation?
For statistical purposes, please indicate:
- None - Under the age of 60 Over the age of 60
- None - Currently in Military Service A Veteran
How did you hear about our complaint form (please choose only one):
- None - Called Phoenix AG Office Called Tucson AG Office Went onto AG Website Visited an AG Satellite Office An Out of State Agency Media: Newspaper/Radio/TV Another Arizona State Agency/State Legislator Attended AG Presentation/Event Contacted Task Force Against Senior Abuse (TASA)
Declaration: I declare under penalty of perjury, that the facts and statements contained in this declaration, including any attached statements, are true, correct, and based upon my personal knowledge. I understand that the information contained in this declaration can only be altered by submitting a new declaration. 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.