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CONSUMER COMPLAINT AGAINST
A BUSINESS/CORPORATION
STATE OF CALIFORNIA DEPARTMENT OF JUSTICE
PIU 2
(Rev. 03/2019)
PAGE 1 of 3
Xavier Becerra
Attorney General
PUBLIC INQUIRY UNIT
(916) 210-6276/ (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/
Mail Form to:
Public Inquiry Unit
Office of the Attorney General
P.O. Box 944255
Sacramento, CA 94244-2550
SECTION 1 - Your Information
First Name Last Name
MI
Mailing Address
County of Residence Country, if not U.S.
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
Date of Transaction
Account Number (if applicable)
Total amount paid
Amount in dispute
How was payment made:
Cash
Check Credit Card
Debit Card
Money Order
Wire Transfer
Finance Agreement
Other
Did you sign a contract or lease?
Yes No
Where was the contract signed?
Starting date
Expiration date
Date you complained to the company or individual
By Mail By Telephone
In Person
Person Contacted
His/Her phone number
Results
What result would you consider fair?
Have you contacted another agency about this?
Yes
No
If yes, name of agency
Do you have an attorney in this case?
Yes
No
If yes, name of your attorney
Attorney's Phone Number
Has your complaint been heard or is it scheduled to be heard in court? Yes
No
If yes, where and when?
If already heard, what was the result?
PLEASE DESCRIBE COMPLAINT ON REVERSE SIDE
Please read the Information Collection, Use and Access
notice on page 3.
E-Mail Address
State
City
Zip Code
Day Phone Number
Cell Phone Number
13-17 18-19 20-29 80 & over12 & under 30-39 40-49 50-59 60-69 70-79
Are you a member of the U.S. Armed Forces
or a dependent? (optional)
Age Range (optional):
Yes
No
Do you have a disability?
(optional)
Yes
No
If yes, please specify your military status:
Active Duty Service Member
Dependent Spouse - Service Member
Dependent Child/Other - Service Member DoD Civilian
Dependent Spouse - DoD Civilian
Dependent Child/Other - DoD Civilian
Military Retiree/Veteran
Reserve Not on Active Duty/National Guard
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