E-Mail:AskConsumerAffairs@lps.state.nj.us

FYI:-

New Jersey Office of the Attorney General
Division of Consumer Affairs
P.O. Box 45025
Newark, New Jersey 07101
(973) 504-6200
(800)-242-5846
E-Mail:AskConsumerAffairs@lps.state.nj.us
Please be advised that any information you supply on this complaint form may be subject to public disclosure. If an
investigation into the matter is conducted, the information is subject to public disclosure only after the investigation is
closed. You are also advised that the completed complaint form is a “government record,” subject to disclosure under the
Open Public Records Act (OPRA).
COMPLAINT REPORTED BY: COMPLAINT REPORTED AGAINST:
NAME: _________________________________________ BUSINESS: ______________________________________
ADDRESS: ______________________________________ ADDRESS: ______________________________________
CITY: __________________________________________ CITY: __________________________________________
STATE: _______________________ ZIP: ____________ STATE: _______________________ ZIP: ____________
HOME TELEPHONE NUMBER: _________________________ TELEPHONE NUMBER (1): ___________________________
WORK TELEPHONE NUMBER: ________________________ TELEPHONE NUMBER (2): ___________________________
E-MAIL ADDRESS: ________________________________
For statistical and informational purposes only. Your age: 18-29 30-44 45-59 60 or older
1. Nature of complaint (please check the appropriate box(es)):
Automotive Automotive Repairs Banking Credit Card
Charity Direct Mail/Sweepstakes Home Repair Internet/Cyberspace
Professional Service Stocks/Securities Telemarketing Telecommunications
Bingo/Raffle Health Club Warranty Advertising
Wheelchair Lemon Law Weighing/Measuring Devices Used Car Lemon Law New Car Lemon Law
Home Furnishings Other (specify) ______________________________________________________________
2. If your complaint involves a motor vehicle, please provide the following information:
a. New Used
b. Purchased Leased
c. Purchase Price ___________________ Current Mileage _________________________
d. Date of purchase______________________ With Warranty With Service Contract As Is
e. Make___________________________ Model _________________________________ Year _____________
3. Name of company with which you dealt: ___________________________________________________________________
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4. Name and title of company agents or employees with whom you dealt: ___________________________________________
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5. Describe the facts of your complaint in the order in which they happened. Please print clearly. Use additional sheets of paper, if
necessary. Attach readable copies (NO ORIGINALS) of any complaint-related contracts, bills, receipts, cancelled checks, correspondence
or any other documents you feel are related to your complaint.
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6. The amount of loss involved in this complaint: $ ______________ . Please provide a breakdown of these losses:
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I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are
willfully false, I am subject to punishment. I authorize the New Jersey Division of Consumer Affairs to send this complaint form to
the company or to interested parties and to use the information in any way that is necessary.
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Signature* Date
* This certification must be signed by the person completing the form. 12/2/05