COMPLAINT FORM

The information you report on this form may be used to help us investigate violations of state laws.  When completed, mail or fax your form and supporting documents to one of the office locations listed above (it is not necessary to submit this form to both locations).  Upon receipt, your complaint will be reviewed by a member of our staff.  The length of this process can vary depending on the circumstances and information you provide with your complaint.  The Attorney General's Office may contact you if additional information is needed.  If you have a claim against the State of Nevada, complete the Tort Claim Form found on our website.  

INSTRUCTIONS:  Please TYPE/PRINT your complaint in dark ink.  You must write LEGIBLY.  All fields MUST be completed.

 

SECTION 1.
COMPLAINT INFORMATION 
Salutation:
                      
Your Name:      
  Last      First MI
Your Address           
  Address                     City State, Zip
Telephone Number           
  Home Cell Work
Email:   Call me between 8am-5pm at:
  Home Cell   Work
  
BUSINESS OR INDIVIDUAL COMPLAINT IS AGAINST  
Business/Provider Name:   Individual/Contact
Individual/Business Address       
Individual/Business Phone:  
Individual/Business Email:         Individual/Business Website:  
SECTION 2.
Did you make any payments to this individual or business?   
How much did the company/individual ask you to pay?  Payment Dates   [None] Select a Date Delete the Date
How much did you actually pay?  $ Payment Method:   
Payment Method:  
Was a contract signed?    If yes, date you signed the contract  [None] Select a Date Delete the Date
Identify your attempts to resolve the issue(s) with the company, corporation or organization.
Have you contacted another agency for assistance?   
 If so, which agency? 
Have you contacted an attorney?   
If so, what is the attorney's name, address and phone number

                             Last                                                                             First                                                                  Phone      

                 Attorney's Street Address                                                                                   Attorney's City, State and Zip Code
Is court action pending?    Have you lost a lawsuit in this matter?   
SECTION 3.
Please detail the nature of your complaint against the individual, business or provider listed in Section 1.  Include the who, what, where, when and why of your complaint. You may use additional sheets if necessary.
My complaint is:
SECTION 4.
List and attach photocopies of any relevant documents, agreements, correspondence, or receipts that support your complaint (examples include billing statements, correspondence, receipts, payment information, witnesses, and any other document which explains or supports the matters raised in the complaint).  No originals.  Copy both sides of any cancelled checks that pertain to this complaint.