Consumer Complaint Form

Commonwealth of Pennsylvania

Office of Attorney General

Please Note: As part of the complaint handling process, the Bureau may send a copy of this form to the individual or company against whom your complaint is filed. Failure to supply your complete and accurate contact information may result in delayed processing of your complaint.

Age Group (for statistical and enforcement purposes)

18-29
30-44
45-59
60 or older

Your Information

Your name:

Address:

City:

County:

State:

Zip Code:

Home telephone number: (###-###-#### format)

Daytime telephone number: (###-###-#### format)

Your email:

Complaint Information

Name of business complaint is against:

Name of individual(s) to whom you complained:

Address:

City:

County:

State:

Zip Code:

Company telephone number: (###-###-#### format)

Product or service purchased:

Date of purchase:

Purchase price:

Other Agencies

Other agencies contacted:

What action was taken:

Have you retained an attorney?

Yes
No

If YES, attorney's name:

Attorney's Address:

Attorney's City:

Attorney's County:

Attorney's State:

Attorney's Zip:

Attorney's Telephone number: (###-###-#### format)

Additional Information

Have you filed a legal action?

Yes
No

If YES, please state WHEN:

WHERE:

WHAT decision was made:

Complaint Information

Please explain your complaint: Try to be brief, but be sure to tell WHAT happened, WHEN it happened and WHERE it happened. Be specific about any oral statements the business made to you, ESPECIALLY those that influenced you to deal with the company. Describe events in the order in which they happened, referring to all contracts, letters, receipts, cancelled checks, advertisements or other papers that will support your claim. If you have documents or other evidence to support your complaint, it will save time if you print out the “pdf” complaint form from this website (http://www.attorneygeneral.gov/uploadedFiles/Complaints/BCP_Complaint_Form.pdf), complete it and mail it to the office with all documentary and other materials related to your complaint.

What would you like the business to do to settle your complaint?

PLEASE READ CAREFULLY

The Attorney General cannot act as your private attorney. As a law enforcement agency, the primary function of the Office of Attorney General is to represent the public at large by enforcing laws prohibiting fraudulent or deceptive trade practices that impact the public interest.

The Attorney General, through the Bureau of Consumer Protection, provides a mediation service to consumers where an attempt may be made to mediate your individual consumer complaint if it falls within the jurisdiction of the office. Please be advised that the information you provide will be shared with the party against which you have filed a complaint. Additionally, your complaint may be shared with or referred to other Governmental Law Enforcement or Regulatory Agencies.

Your complaint will also be kept on file with our office and the information contained therein may be used to establish violations of Pennsylvania Law. Attached to this complaint form is an informational sheet which will help you in completion of the complaint form and also will explain in greater detail the mediation process.

By completing and submitting this complaint form, I am adopting this as my online signature and I authorize the Bureau of Consumer Protection to contact the party(ies) against which I have filed a complaint in an effort to reach an amicable resolution. I further authorize the party(ies) against which I have filed a complaint to communicate with and provide information related to my complaint to the Bureau of Consumer Protection. I verify that I have read and understand the informational sheet about this process; and, that the information provided is true and correct to the best of my knowledge, information and belief.