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Passenger Transportation Regulatory Division
Passenger'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)
Cell No.:
(no dashes)
Home No.:
(no dashes)
E-mail:
*
Driver and Vehicle Information
Date of Incident:
*
(xx/xx/xxxx)
Time of Incident:
*
(xx:xx)
Point of Pick Up
*
Destination:
*
Driver Name:
Driver Reg. No.:
Company Name:
Telephone:
(no dashes)
For-Hire Vehicle No.:
Tag No.:
Description of Driver :
Description of Incident
*
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) 372-6320 or send it by regular mail to the Passenger Transportation Regulatory Division, 140 West Flagler Street, Suite 904, 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/transportation operator for their response.
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