Charles H. Bronson, Commissioner - LuAnn Stiles, Director

Consumer Complaint Form

Please fill out ALL information. Incomplete forms CANNOT be processed. DO NOT use this complaint form for  Do Not Call complaints or  Motor Vehicle Repair complaints. Supporting documents can be attached after successful complaint submission.

The fields with (*) asterisks by them are REQUIRED fields.  Our system will not process this form without the REQUIRED fields.

Please select the subject area of your complaint*

Consumer Information
Name*


           First                    Middle                    Last  

Country*
Address*  
City*  
State/Province*    Zip  

Email*

 
Age Group* Some age groups may receive special protection under Florida law.  
Home Phone*   XXX-XXX-XXXX       
Work/Cell Phone   XXX-XXX-XXXX     

Business Information (Complaint Filing Against)
Name*

 
Address*  
City*  
State/Province*       Zip  
Phone*   XXX-XXX-XXXX     

Product Information
Date of Purchase MM/DD/YYYY

 
Mode of Contact*    
Product or Service Involved
Cost of Product or Service
in US Dollars, e.g. 9426.38 		$  

Did you sign a contract or any other similar documents?*

 

When   MM/DD/YYYY

 
Where
Are you currently represented by a lawyer? *
If so, you should rely on the advice of your lawyer. 		 
Have you filed suit in court? *  

Explain your complaint, describing the events in the order in which they occurred. *

What would satisfy your complaint?

Authorization

 *
authorize you to send a copy of my complaint to the business I am complaining about or to any other government agency necessary for purposes of mediation, investigation or enforcement."

I acknowledge that I am aware that all information I provide with my complaint, except credit card numbers, is a matter of public record and is not considered confidential.

False Official Statements

Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082, s.775.083, or s. 775.084, Florida Statutes.

* 

Department of Agriculture and Consumers Services' Role

I understand that your office does not give legal advice. I also understand that your office cannot take legal action for me. I am filing this complaint to notify your office of the activities of this business/individual and to seek any assistance you may be able to render.

*

Certification
By choosing to submit this form electronically, I certify and agree that by entering my name in the space below, I bind and legally obligate myself to the same extent as I would by signing my name on a printed paper version of this form.
Date*  MM/DD/YYYY