State of Alaska Office of the Attorney General 1031 W. 4th Ave., Suite 200 Anchorage, AK 99501-5903

www.law.alaska.gov/consumer

CONSUMER COMPLAINT

Office Use OnlyComp. # I.C.Prac. Code:Analyst:Disp. Code:Date Rec'd:

READ THE FOLLOWING BEFORE COMPLETING THE COMPLAINT FORM In filing this complaint, I understand: 1. The Attorney General is not my private attorney and cannot provide legal advice to me. 2. I authorize the Attorney General to send this complaint to the business or organization named below, or to refer

the complaint to other appropriate agencies. 3. The information in this complaint is true and correct to the best of my knowledge.

CONSUMER INFORMATIONName:Mr. Mrs.Ms.

(First) (Last) Age:

Address: Apt. #:

City, State, Zip

Work Phone #: Home #:

Email address:

BUSINESS INFORMATIONBusiness or Organization Your Complaint is Against:

Address:

City, State, Zip

Phone #: Email address:

Contact Person:

Website Address:

INFORMATION ABOUT THE TRANSACTION OR EVENT

Date of transaction or event:

Did you sign a contract? If so, please attach a copy.

Product or service involved:

Amount paid: $ Paid By: Cash Check Credit Card Loan

Did you see or hear an advertisement for the product or service? If so, where and when?

First contact between you and the company: (check one)

Person came to my houseI telephoned the companyI responded to a radio/tv adI received information in the mailI went to the company's place of businessI received a telephone call from companyInternetOther (explain)

Where did the transaction take place: (check one)

Over the phoneAt homeAt the companyBy mailInternetOther (explain)

RESOLUTION SOUGHTWhat would you consider a satisfactory resolution to this matter?

Refund Product Delivery Service Performed Other (explain)

If you are seeking a refund, please state the amount: $

I am not seeking a resolution to this matter, but am filing a complaint for reporting purposes only.

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ACTION YOU HAVE TAKENHave you complained to the business or organization? Yes No (If so, attach a copy of complaint)

How? Mail By telephone In person Date of complaint

Person contacted: Job title:

Nature of response: Date of Response:

Have you retained an attorney regarding this complaint? Yes NoIf so, please state the name, address, and phone number of your attorney:

Yes NoIf so, please describe the current status of any legal action:Has legal action been taken by you or against you with regard to this complaint?

Have you filed this complaint with any other agencies? Yes No If so, list name of agency and status of complaint:

DESCRIPTION OF TRANSACTION OR EVENTDescribe the transaction or event, using additional sheets if necessary. Tell us WHAT happened, WHEN it happened, WHERE it happened, and WHY it was unfair or deceptive. Attach COPIES of all contracts, letters, receipts, advertisements, or any other papers that relate to your complaint.

Page 2 of 2 Revised 1/2012

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