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Consumer Complaint Form


Authorization, Signature, and Disclaimer For Paper Submission

Electronic complaint submission is preferred. Only use this section if you are having difficulty submitting your form electronically.

If you are unable to submit this form electronically and choose instead to print and mail it, you must sign below and mail or fax to:

Office of the Attorney General of Virginia
Consumer Protection Section
900 East Main Street
Richmond, VA 23219
Fax: (804) 225-4378

I agree with the following conditions:

  • All information provided to this Office is available for public inspection under the Virginia Freedom of Information Act, Va. Code Section 2.2-3700 et seq., except in the case of ongoing investigations. Closed complaints will be retained for three years after closure and then destroyed.
  • The information requested on this form and on any subsequent requests for additional information is subject to the Virginia Government Data Collection and Dissemination Practices Act, Va. Code Section 2.2-3800 et seq.
  • By submitting this form, you authorize the Office of Consumer Affairs and any other local, state or federal agencies to which we may refer your case, to evaluate your complaint, to contact you and to take whatever lawful actions are deemed appropriate in your case.
  • By submitting this form, you certify that the statements made herein or on any attached documentation are true and complete to the best of your knowledge, information and belief.

Unsigned complaint submissions cannot be processed!


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Signature

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Printed Name

___________________________________________

Date



Before you submit a complaint, please click here for important information

If possible, please have any supporting documents ready to upload in electronic format (computer files or scanned documents) before you begin filling out this online form.

* indicates required field
* Prefix
* First Name
Middle Initial
* Last Name
Suffix
* Mailing address
Apt. or suite number
* City
State
Zip code
Region and Country, if not U.S.
Home phone, including area code
Work phone, including area code
Fax number, including area code
* City or county of residence
Your e-mail address
* Contact preference
Best time to reach you between 8AM and 5PM?

* Full name of company
* Mailing address
Office or suite number
* City
State
Zip code
Region and Country, if not U.S.
If you do not know the Mailing address, please describe where the business is located.
Company’s Internet address (URL)
Telephone number, incl. area code
Fax number, including area code
Other contact number, including area code

* Type of product, item, or service involved  
Additional Information about Product Type, etc.
Manufacturer, make or brand
Model
Year
Serial number, Vehicle Identification Number (VIN)
Date of purchase or lease  
Was this a new or used item?
Did you sign a contract or lease?
If yes, Starting date  
Ending date  
Total amount paid
$
 
Total amount in dispute
$
 
How was payment made?







Did you buy an extended service contract?
If yes, name of company responsible for extended service contract or extended warranty
For automobile complaints, indicate type of repairs or services performed (Air conditioner, brakes, oil change, transmission, etc.)
Before any work was performed, did you ask for and receive a written copy of the cost estimate?
Did you authorize any changes to the original estimate?
If yes, please provide details in section 4
Were the completed repairs different from what you had authorized?
If yes, please provide details in section 4

* Enter a description of the complaint

Have you contacted the company?
If yes, name of person most recently contacted
Their phone number, incl. area code
* What resolution are you seeking?
List any other organizations you have contacted (i.e., other consumer protection offices, Better Business Bureau, etc.)
Do you have an attorney in this case?
If yes, name of your attorney
Attorney’s number, incl. area code
* Has your complaint been heard or is it scheduled to be heard in court?
* If yes, when and where?

Select the Upload File(s) button to upload pertinent documents or images