9. DID YOU SIGN ANY WRITTEN AGREEMENT? IF YES, PLEASE ATTACH A COPY OF THE AGREEMENT. Yes No

Itelephonedthefirm Iwenttothefirm’splaceofbusinessIrespondedtoaTV/radioad IreceivedatelephonecallfromthefirmApersoncametomyhome IrespondedtoanofferontheInternetIreceivedinformationbye-mail IrespondedtoaprintedadvertisementIreceivedinformationinthemail Other______________________________________

Topreventdelay,pleasebesuretocompleteboth sidesofthisforminfull.Pleaseprintclearlyortype.DO NOTincludeyourSocial Security Numberonthisformorinanyaccompanyingdocuments.

4. WHERE DID THE TRANSACTION/INCIDENT YOU ARE COMPLAINING ABOUT TAKE PLACE? (Check box when applicable)

Atthefirm’splaceofbusiness ByMailMyhome ByInternet/e-mailAwayfromthefirm’splaceofbusiness(work,convention,etc.)BytelephoneOther__________________________________________

5. WHAT WAS THE VERY FIRST CONTACT BETWEEN YOU AND THE FIRM?

7. WHAT WAS THE TRANSACTION FOR?

MybusinessMyfamily/householdMyfarm

6. DO YOU CONSENT TO DISCLOSING THE FOLLOWING TO THE PUBLIC?

Thenatureandstatusofyourcomplaintandthenameofthefirm?YesNoYourname? YesNoYourphonenumber? YesNo

8. HOW DID YOU PAY?

CashCreditCardMedicaid PrivateInsuranceCheckInstallmentLoanMedicare Other___________________________

Ind Prac OA: Inv. Sec File#PL MO NL NJ

-CP-

ForOfficeUseOnly:

3. WHEN DID TRANSACTION/INCIDENT OCCUR?Date Time AM PM

CONSUMER COMPLAINT FORM Office of the Indiana Attorney General

1. YOUR INFORMATION

Mr.Mrs.MissMs.Dr.Name__________________________________________

Address________________________________________

City ___________________________ State__________

ZIP______________________ County_______________

Age

Phone______________________________________ Day

___________________________________ Evening

E-mail__________________________________________

()

()

2. WHO IS YOUR COMPLAINT AGAINST?

Name/Firm______________________________________

______________________________________

Address________________________________________

________________________________________

City ___________________________ State__________

ZIP______________________ County_______________

Phone__________________________________________

E-mail__________________________________________

Personyoudealtwith______________________________

()18-2425-3435-4445-5455-6465+

TheConsumerProtectionDivisionwillsendacopyofyourcomplainttotherespondentfirmorlicensedprofessional.Thisofficecannotdiscloseyourcomplaintagainstalicensedprofessionaltothepublicunlessthisofficefilesadisciplinaryactionagainstthelicensedprofessional.ThisofficerepresentstheStateofIndianaandislimitedintheremediesitcanpursue.Youmaybeentitledtocompensationorotherrightsthatwecannotpursueforyou.Inadditiontofilingthiscomplaint,youmaywanttoconsidercontactingaprivateattorneyoryourlocalsmallclaimscourt.

MAIL COMPLETED FORMS TO:

AttorneyGeneralGregZoellerConsumerProtectionDivision

GovernmentCenterSouth,5thfloor302WestWashingtonStreet

Indianapolis,IN46204PH:317-232-6330•FAX:317-233-4393

www.IndianaConsumer.com

Iaffirm,underthepenaltiesforperjury,thattheforegoingrepresentations,andthoseinallattachments,aretrue.TheinformationIhaveprovidedinthiscomplaintformisbaseduponmypersonalknowledge.IconsenttotheConsumerProtectionDivisionobtainingorreleasinganyinformationinfurtheranceofthedispositionofthiscomplaint.IunderstandthatIshouldnotincludemySocialSecurityNumberinanyinformationsubmittedtotheConsumerProtectionDivision.IfIdoprovidemySocialSecurityNumber,IexpresslyconsenttothedisclosureofmySocialSecurityNumberinaccordancewithIndianaCode§4-1-10-5(2).

YourSignature Date

When?_______________________________________Actiontaken?__________________________________________ __________________________________________

Pleaseattachacopyofallpapersinvolved(orderblank,warranty,creditcardreceiptandstatement,invoice,contractorwrittenagreement,advertisement,cancelledcheck,correspondenceandallotherrelateddocuments).Pleaseprintclearlyortype.DONOTINCLUDEYOURSOCIALSECURITYNUMBER.

Rev.01-09

11. WITH WHAT OTHER AGENCY HAVE YOU FILED THIS COMPLAINT?

When?_______________________________________Actiontaken?__________________________________________

12. HAVE YOU CONTACTED A PRIVATE ATTORNEY? YesNo

13. HAVE YOU STARTED A COURT ACTION? IF YES, PLEASE ATTACH A COPY OF ALL COURT PAPERS. YesNo

14. HAVE YOU BEEN SUED OVER THIS ISSUE? IF YES, PLEASE ATTACH A COPY OF ALL COURT PAPERS. YesNo

17. HOW WOULD YOU LIKE YOUR COMPLAINT RESOLVED?

18. CONSENT AND VERIFICATION

16. PLEASE DESCRIBE YOUR COMPLAINT IN DETAIL (ATTACH ADDITIONAL PAGES IF NECESSARY)

10. HAVE YOU COMPLAINED TO THE BUSINESS? (Check box when applicable) YesNo

WHAT WILL HAPPEN NOW? WHAT ELSE SHOULD YOU DO?

15. DOLLAR AMOUNT ASSOCIATED WITH YOUR LOSS, IF ANY. $__________