KWAMERAOUL
Illinois Attorney General Office Use Only
Consumer Fraud Bureau
5 00 South Second St. CLMS:
Springfield, IL 62701
1-800-243-0618 AG:
Individuals with hearing or speech disabilities
can reach us by using the 7-1-1 relay service.
[Link]
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Fill out the form online, then print and mail to the address above. Include copies (no originals please) of any supporting documents.
YOUR INFORMATION: �NAME OF SELLER OR PROVIDER OF SERVICE:
Name: Mr.1 Mrs.I Ms. 1 (check one) Name:
Address:
Address:
City: State: ZipCode:
City: State: ZipCode: County:
Telephone: - - Ext.:
Website:
Your Telephone Number:
Additional seller or provider of service involved in transaction:
Daytime: - - Ext.:
Name:
Evening: - - Ext.:
Address:
Your e-mail address (optional):
City: State: ZipCode:
Are you a senior citizen? Yes □ No □
Are you a veteran? Yes □ No □ Telephone: - - Ext.:
Are you a service member? Yes □ No □ Website:
Has this matter been submitted to another government agency, an arbitration service, or to any attorney? Yes D No □
Ifyes, please give name, address, telephone:
Is court action pending? Yes D No □
INFORMATION ABOUT THE TRANSACTION
Date ofTransaction: Did you sign a contract? Date contract was signed:
I YesO No 0 I
(If yes, please attach a copy)
Was the product or service advertised? YesO No □ When? (Please attach a copy of the advertisement, if applicable.)
How was the service advertised?
D Newspaper/magazine TotalCost ofproducUservice: $0.00
D Radio advertisement Amount paid to date/down payment: $0.00
D Television advertisement
D Internet advertisement Method of payment (check one) (Please attach a copy.)
D E-mail solicitation
D Direct mail solicitation CashO Check □ Money Order D CreditCard D DebitCard 0 BankDraft 0
D Telephone solicitation
D Yellow pages ofthe telephone book
Wire Transfer D Automatic Debit □ Other
D Facsimile solicitation Ifyou paid with a credit card, have you contacted your credit card company to register
D Door-to-door solicitation a dispute? Yes □ No □
D Display at merchant's place ofbusiness
D Display at a trade show/convention, etc. (Under the Federal Fair Credit Billing Act, you have 60 days from the time that you receive
D Other your statement to dispute the charge.)
Where did the transaction take place? Have you complained to the company or individual?
D Atmyhome YesD No □
D Over the telephone
D By mail
D Over the Internet If yes, provide name and phone number of the individual(s):
D Trade show/convention/home show
D At the firm's place of business
D By facsimile
D Other (Please specify)
D There was no transaction
FOR COMPLAINTS REGARDING MOTOR VEHICLES, PLEASE COMPLETE TIDS BOX:
Make: Model: Year: New: Yes D No □ As-Is: Yes D No □
Warranty: YesD No □
Name of Extended Warranty: Purchase Date: Current Mileage: Mileage at Purchase:
Expiration Date:
Briefly describe the transaction and your complaint. You may use additional sheets if necessary. Please attach copies of all contracts,
letters, receipts, cancelled checks (front and back), advertisements, or any other documents that relate to your complaint.
PLEASE DO NOT SEND ORIGINALS.
What form ofrelief are you seeking? (E.g., exchange, repair, money back, product delivery, etc.)
I I
READ THE FOLLOWING BEFORE SIGNING BELOW:
• In filing this complaint, I understand that the Attorney General is not my private attorney, but rather enforces laws designed to
protect the public from misleading or unlawful practices. I also understand that if I have any questions concerning my legal rights or
responsibilities, I should contact a private attorney. I have no objection to the contents of this complaint being forwarded to the
business or the person the complaint is directed against, unless the box below is checked.
• By filing this complaint, I hereby give the business complained about my consent to communicate, including disclosure of non-
public personal information, with the Office of the Attorney General about any and all matters connected with this complaint.
Signature: Date:
D Please do not send this complaint to the business complained about.
Please print and send the completed form to the address at the top of this complaint form.
Rev. 1/17/2019 (sd)