File a Complaint Form

Your Information
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Birth year (for statistical purposes only)*
Phone
Email
Complaint Information

Enter the details of the company or person who committed the fraud.
Company name
Company name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Web Address
Phone Number
How did you first encounter this company/individual
Type of Complaint
Date of first contact with seller/company
MM slash DD slash YYYY
If the seller/company asked for money, how much?
If you paid the seller/company, how much?
How did you pay?
Comments

Explain what happened; what goods or services were offered, if any; what you have tried to do to resolve the problem; and any other details you think are important that were not captured in the form above. Please provide as many details as you can. Thank you.
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