To prevent delay, please fill out the form completely and answer all of the questions. DO NOT include your Social Security Number on this form or any accompanying documents.
"*" indicates a required field .
1. Your name?
Mr. Ms. Mrs. Miss Dr. *Name: First: Middle Initial: *Last Suffix: *Address: *City: *State: *County: *Zip: *Daytime Phone (include area code): *Evening Phone (include area code): Age: 18-24 25-34 35-44 45-54 55-64 65+ E-mail: (If you would like a copy of your complaint emailed to you, please include your valid email address)
2. Who is your complaint against?
*Name/Firm: Address: City: *State: County: Zip: Phone (include area code): Type of Business: None Specified Auto - New Sales Auto - Used Sales Auto Repair & Supply Mail Order Sales Door-to-Door Sales Misc. Home Remod/Improvement Plumbing Household Appliances Food Freezer Meats Employment Services Private Schools Collection Agencies Real Estate Moving & Storage Health Spas & Weight Loss Prof Serv at Conversion Agricultural Supplies Financial Institution Franchises Securities Public Utilities Insurance Manufactured Homes Recreational Vehicles Energy/Heat/Air Air Conditioning Consumer Electronics Landlord-Tenant Buying Services Coop Tools & Equip Rental Hardware Sales Furniture Sales & Service Clothing Misc. Personal Goods Debt Consolidation Television Radio Repair Watch Repair Auto Leasing Consumer Lending Institution Commodity Sales Credit Card Service Companies Motocycle Sales/Service Bicycle Sales/Service Photographic Sales Photographic Service Water Treatment/Well Waterproofing Pest Control Motels & Hotels Sporting Goods Loan Finding, etc. Concerts Vacation Plans/Agent Hospitals Beauty Aids & Products Burglar Alarms Cemeteries, etc Computer Dating Magazine Sales Record Clubs Heating Oil/Bottle Gas Hearing Aid Sales Accountants Auctioneers Architects Barbers Beauty Culturists Boxing Chiropractors Dentists Embalmers & Funeral Directors Engineers & Land Surveyors Health Facility Administrators Medical Doctors Nurses - Registered Optometrists Pharmacists Environmental Health Specialists Psychologists Speech Pathologists Veterinarians Opticians Audiologists Nurses - Licensed Practical Nurse-Practitioner Fundraiser - Registered Podiatrists Physical Therapists Dry Cleaning Jewelry Business Opp. Reg Person you dealt with: E-mail (Optional):
*3. First Contact Between You and the Firm?
A person came to my home I went to the firm’s place of business I responded to a TV/radio ad I received a telephone call from the firm I telephoned the firm I received information in the mail I responded to an offer on the Internet I received information by e-mail I responded to a printed advertisement Other:
*4. Where Did the Transaction Take Place?
My home At the firm’s place of business Away from the firm’s place of business (work, convention, etc.) By telephone By mail By Internet/e-mail Other:
*5. State the date(s) on which you entered into this transaction:
*6. What was this transaction for? My business My family/household My farm
*7. How did you pay?
Cash
Private Insurance
Credit Card
Medicare
Check
Medicaid
Installment Loan
Other
*8. Did you sign a contract or written agreement? Yes No If yes, you will need to attach a copy, so you should download a form and mail it instead of using this online form.
*9. Do you consent to the Consumer Protection Division disclosing to the public the following (answers required):
The nature and status of your complaint and the name of the firm?
Yes
No
Your name?
Your telephone number?
*10. Have you contacted the firm your complaint is against? Yes No If yes, when?
11. What action was taken?
12. With what other agency have you filed this complaint?
13. What action was taken?
*14. Have you contacted a private attorney?
*15. Have you started court action?
*16. Have you been sued over this issue?
*17a. Which of the following best describes your complaint? Type of Complaint Failure to Deliver Failure to Refund Deposit Failure to Honor Warranty Failure to Perform Misrep. Repairs Needed Incorrect Billing Misrep. Availability Misrep. Used as New Odometer Violation Misrep. School/Course Misrep. Terms of Contract Out-of-Business Misrep. Brand/Manufacturer Fail to Refund Incorrect Weight/No. 3-Day Cancel Violation Fail Honor 3-Day CO Price Savings Claim Fail Disclose Odometer Misrep. Quality Buy Club Excess 5 Years High Pressure Sales Misrep Quantity Breach of Bailment Unsatisfactory Performance Misrep. Affiliation Misrep. Scope License Unlicensed Practice Pyramid Scheme Referral Sales Unauthorized Service/Repairs Illegal Contest Fail Honor Estimate Professional Malpractice Criminal Violation Refuse Cancel Contract Unsafe Product Drug/Alcohol Abuse: Personal Unregistered Lewd/Immoral Conduct Unregistered Time Share Unregistered Camp Club Fail to Complete Contract Unregistered Professional Fund Raiser Unprofessional Conduct Drug Diversion Drug Diversion Abuse Unsolicited Merchandise Failure to Convey Title Overcharge Registration Application Filed Misrep. Used as Donation Fail to Disclose Fundraiser Poor Workmanship Defective Product Damage of Property Fail to Provide Rec/X-Ray DOI - Department of Insurance Billing Dispute Patient Abuse Unnecessary Treatment Criminal Conviction/Plea Product Defect Nat'l Practitioner Data Bank Fail to Make Disclosures Criminal Arrest Health Investigation Violation of Patient Confidentiality Application/Renewal Fraud False Advertising Physical/Mental Disability Failure to Supervise Denture Complaint Misfill of Prescription Eyeglass Prescription Fraudulent Prescription DUI - Driving Under the Influence Rudeness Other Drug Related Conduct Violation of Probation Professional Incompetence Insurance Fraud Misdiagnosis Falsifying Records None of the Above
*17b. Please summarize your complaint: (1200 character limit)
*18. How would you like your complaint resolved? (300 character limit) What will happen now? What else should you do?
The Consumer Protection Division will send a copy of your complaint to the respondent firm or licensed professional.
This office cannot disclose your complaint against a licensed professional to the public unless this office files a disciplinary action against the licensed professional. This office cannot disclose your complaint against any other person or firm without your consent.
This office represents the State of Indiana and is strictly limited in what remedies it can pursue. You may be entitled to compensation or other rights that we cannot pursue for you. In addition to filing this complaint, you should contact a private attorney or a small claims court.
By clicking “Submit”, you affirm that the information on this form, under the penalties for perjury, that the foregoing representations, and those in all attachments, are true. The information I have provided in this complaint form is based upon my personal knowledge. I consent to the release of any information to the Consumer Protection Division relating to this complaint. I understand that I should not include my Social Security Number in any information submitted to the Consumer Protection Division. If I do provide my Social Security Number, I expressly consent to the disclosure of my Social Security Number in accordance with Indiana Code § 4-1-10-5(2).
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