Response

Fields with an * are required

Consumer Information

Prefix

First Name

Last Name

Suffix

Address Line 1

City

State

Zip

Home Phone

Work Phone

Cell Phone

Business Information

Business Name

Address Line 1

Address Line 2

City

State

Zip

Work Phone

Business Website

Manufacturer

Address Line 1

Address Line 2

City

State

Zip

Business Phone

Consumer Questions

What is the product or service you are complaining about?

Motor Vehicle Information

New or Used Car?

Date of Purchase

Vehicle Year

Vehicle Make

Vehicle Model

Vehicle Vin #

Mileage at Purchase

Current Mileage

Prior Use

How Acquired?

Mechanical Defects, If Any Known

Prior Substantial Damage to Body or Engine, If Any Known

Did you receive a Dealer Express Warranty?

Warranty Type

% of Labor

% of Parts

Date Problem Occurred

Purchase Price

Warranty

Length of Warranty

Did you sign a contract? If so please include a copy

Did you receive a warranty?

Describe the warranty (4000 Characters Max)

Date of Transaction

Amount Paid

Was the product or service advertised?

If yes, was the advertisement accurate?

Have you submitted this matter to another agency or lawyer?

Agency's or lawyer's name and phone number

Have you sued the company or has the company sued you?

May we send a copy to the business? *(If you check "No" we will not be able to mediate your complaint. However, we will keep your complaint on file.)

Summary of Complaint (4000 Characters Max)

How did the business respond to your complaint? (4000 Characters Max)

What do you believe would be a fair resolution of your specific complaint? (4000 Characters Max)

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Thank you for submitting your complaint. You will be able to submit additional documentation or information later by replying to any email we send to you regarding this issue or by mailing copies to us. We will not be able to return documents.

If your complaint is determined to be one we can offer to mediate, we will send a letter to both you and the business discussing the next step in mediation. Our service is voluntary and we cannot make either party accept any result. While our office can try to bring people together to discuss a problem, it is all parties' willingness to seek a resolution that achieves results