Submit a Complaint

Complaint
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Notice Under State Law

Tell Us About Yourself

Complaint No.

Title

First Name

Last Name

Address 1

Address 2

City

State

Zip Code

Email Address

Property Address

Primary Phone

Other Phone

Are you currently in the United States Military?

NoYes

Branch of Military

Age

What is the best way to contact you?

Have you contacted the financial institution, business, firm or individual(s) regarding your complaint? If Yes, include name, dates and results of your contact(s) in Complaint Description below. Attach copies of all related documents.

NoYes

Please clearly describe the events in order in which they occurred. Include full names, addresses, a description of the problem with the amount(s), date(s) of any transaction(s) and the contact information of any witnesses, and any other relevant information that may assist us in resolving your complaint. Please state if you have filed a lawsuit or arbitration for this complaint. For your protection, DO NOT INCLUDE PERSONAL CONFIDENTIAL INFORMATION SUCH AS YOUR SOCIAL SECURITY NUMBER

Inquiry/Complaint Description

Who Are the Persons/Businesses Involved?

Organization Name(s)

Individual Name(s)

Organization Address

What do you believe would be a fair resolution to this matter?

In submitting this complaint, you agree the information provided is true and correct to the best of your knowledge and that the information may be used by the Department for its investigation. Consumer complaints are considered to have been received by the Department in confidence. However, the Department may, at its sole discretion, disclose your complaint to the person or entity for the purpose of corrective action. The Department may also choose to disclose your complaint to others for the purpose of facilitating an investigation of the person or entity complained against or initiating legal proceedings against the same under the Department's investigation.