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State of Calofornia Complian Form

This 3-page document is a consumer complaint form from the California Department of Justice that allows individuals to file complaints against businesses. The form collects contact information for the complainant and details about the transaction in question. It explains that the information provided will be used to review the complaint and may be shared with other government agencies or the business being complained about.

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boytoy 9774
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36 views

State of Calofornia Complian Form

This 3-page document is a consumer complaint form from the California Department of Justice that allows individuals to file complaints against businesses. The form collects contact information for the complainant and details about the transaction in question. It explains that the information provided will be used to review the complaint and may be shared with other government agencies or the business being complained about.

Uploaded by

boytoy 9774
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

STATE OF CALIFORNIA

PIU 2
(Rev. 02/2014)

DEPARTMENT OF JUSTICE
PAGE 1 of 3

CONSUMER COMPLAINT AGAINST


A BUSINESS/CORPORATION

Mail Form to:

Please read the Information Collection, Use and Access


notice on page 3.

Kamala D. Harris
Attorney General

PUBLIC INQUIRY UNIT


(916) 322-3360/ (800) 952-5225 Toll Free - CA only
TTY/TDD (800) 735-2929 (California Relay Service)
For TTY/TDD outside California contact your state's relay service
number at http://www.fcc.gov/cgb/dro/trsphonebk.html
AG Web Site: http://www.ag.ca.gov/

Print Form

Public Inquiry Unit


Office of the Attorney General
P.O. Box 944255
Sacramento, CA 94244-2550

Save Form

Reset Form

SECTION 1 - Your Information


Mr. Ms. Mrs.

First Name

Last Name

MI

Mr
Mailing Address

City

County of Residence
Do you have a disability?
(optional)

Country, if not U.S.

Yes

Are you a member of the U.S. Armed Forces


or a dependent? (optional)
Yes

18-19

20-29

If yes, please specify your military status:


Active Duty Service Member

No

30-39

40-49

Zip Code

E-Mail Address

Cell Phone Number

Day Phone Number

Age Range (optional):


12 & under
13-17

No

State

50-59

60-69

70-79

Dependent Spouse - Service Member


Dependent Spouse - DoD Civilian

Dependent Child/Other - Service Member

DoD Civilian

Dependent Child/Other - DoD Civilian

Military Retiree/Veteran

Reserve Not on Active Duty/National Guard

SECTION 2 - Information About Company Against Which You Are Complaining


Full Name of Company
Mailing Address
City

State

Zip Code

Country, if not U.S.

Company's Internet Address (URL)

E-Mail Address

Telephone Number

Fax Number

SECTION 3 - Complaint Information


Product, item or service involved
Account Number (if applicable)

Date of Transaction
Total amount paid

How was payment made:


Check
Cash

Amount in dispute

Wire Transfer
Did you sign a contract or lease? Where was the contract signed?
Yes
No
Date you complained to the company or individual
By Mail

By Telephone

Credit Card

Finance Agreement

Debit Card

Money Order

Other

Starting date

Expiration date

Person Contacted

His/Her phone number

In Person

Results
What result would you consider fair?
Have you contacted another agency about this?

Yes

Do you have an attorney in this case?

No

Yes

No

If yes, name of agency

If yes, name of your attorney

Has your complaint been heard or is it scheduled to be heard in court?

Yes

80 & over

No

If yes, where and when?


If already heard, what was the result?
PLEASE DESCRIBE COMPLAINT ON REVERSE SIDE

Attorney's Phone Number

STATE OF CALIFORNIA
PIU 2
(Rev. 02/2014)

Kamala D. Harris
Attorney General

DEPARTMENT OF JUSTICE
PAGE 2 of 3

CONSUMER COMPLAINT AGAINST


A BUSINESS/CORPORATION

SECTION 4 - Information About the Transaction


How was initial contact made between you and the business?

Where did the transaction take place?

Person came to my home

At my home

I went to company's place of business

At company's place of business

I received a telephone call from business

By mail

I telephoned the business

Over the phone

I received information in the mail

Via computer (website or e-mail)

I responded to a radio/television ad

Trade show or convention

I responded to a printed advertisement

Other

I responded to a website or e-mail solicitation


I received a fax solicitation
I attended a trade show or convention
Other

SECTION 5 - Important Information

If the complaint falls within the jurisdiction of another local, state or federal agency, you will be provided with appropriate referral information.
In addition, the complaint may be shared with other government agencies.
Please include copies of any supporting documents you may have, such as correspondence, contracts, invoices, receipts, etc. Do not send
originals.
This office does not have the authority to give private legal advice or provide private legal representation to individual consumers.

SECTION 6 - Details of Complaint (use additional sheets if necessary)

SECTION 7 - Statement
I affirm that the information herein is true and accurate, and will sign a statement if needed.

YES

NO

You may send this complaint to the party named. 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.

YES

NO

Signature:

Date:

STATE OF CALIFORNIA
PIU 2
(Rev. 02/2014)

Kamala D. Harris
Attorney General

DEPARTMENT OF JUSTICE

CONSUMER COMPLAINT AGAINST


A BUSINESS/CORPORATION

PAGE 3 of 3

Collection and Use of Personal Information. The Public Inquiry Unit in the Department of Justice collects the
information requested on this form as authorized by Government Code Sections 11180, 11181, and 11182. The
Public Inquiry Unit uses this information to review your complaint. In addition, any personal information collected
by state agencies is subject to the limitations in the Information Practices Act and state policy. The Department of
Justice's general privacy policy is available at http://oag.ca.gov/privacy-policy.
Providing Personal Information. You do not have to provide the personal information requested. If you do not
wish to provide personal information, such as your name, home address, or home telephone number, you may
remain anonymous. In that case, however, we may not be able to contact you or help resolve your complaint.
Access to Your Information. You may review the records maintained by the Public Inquiry Unit in the Department
of Justice that contain your personal information, as permitted by the Information Practices Act. See below for
contact information.
Possible Disclosure of Personal Information. In order to follow up on your complaint, we may need to share the
information you give us with the party you complained about or with other government agencies.
The information you provide may also be disclosed in the following circumstances:
With other persons or agencies where necessary to perform their legal duties, and their use of your
information is compatible and complies with state law, such as for investigations or for licensing,
certification, or regulatory purposes;
To another government agency as required by state or federal law;
Contact Information. For questions about a written comment or complaint that you submitted to the Public
Inquiry Unit, please fill-out and submit our online form, available at:
http://oag.ca.gov/contact/general-comment-question-or-complaint-form
Please specify in the "Your Comments" section the specific Public Inquiry Unit record that you are seeking. Or you
may mail your request to Analyst, Public Inquiry Unit, Office of the Attorney General, P.O. Box 944255,
Sacramento, CA 94244-2550. In addition, if you are seeking records maintained by another Department of Justice
program, you should contact that program directly.

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