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Consumer Complaints

Consumer's Contact Information
* Required fields
Temporary Complaint No.: * (Use last 4 digits of your home telephone number)
First Name: *
Last Name: *
Address: *  
City : *
State : *
Zip: *
Daytime No: * (no dashes)
Home No: *
(no dashes)
Cell No.: (no dashes)
E-mail: *
Have you engaged an attorney? * Y N
Have you filed this complaint with another agency? * Y N
If yes, name of agency:
Your age category: under 20
  60-69
Company Information
Company Name:   *  
Address: *
Suite/Apt #:
City: *
State : *
Zip: *
Telephone: (no dashes)
Ext:
Web URL:
Company Email:
Name of person you spoke to at the Company:
Other Information
If this is a motor vehicle repair complaint please state:
Make of Vehicle : Year : Model :
Do you wish to receive Consumer Protection information and notices?  
  Yes No
 
State Your Experience Briefly
 
How would you like your complaint resolved?
 
You may email this form directly to the Consumer Mediation Center by clicking on Submit. You may also print and fax it to (305) 375-4120 or send it by regular mail to the Consumer Mediation Center, 140 West Flagler Street, Suite 902, Miami, Fl. 33130.

By submitting this complaint affidavit I declare, under penalties of perjury, that I have read the foregoing complaint affidavit, that the facts stated in it are true and that any supporting documentation I submit will be copies of genuine documents. I understand further that my complaint is a public record and that a copy of this complaint will be sent to the business operator for their response.



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Back to Top Page Last Edited: Fri May 31, 2013 12:14:34 PM
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