Charles H. Bronson, Commissioner - LuAnn Stiles, Director

Motor Vehicle Repair Consumer Complaint Form
Chapter 570.544(3) F.S.

Please fill in all information. Incomplete forms cannot be processed. Fields with the red asterisk (*) are required fields. Once this form has been completed and submitted, a copy of your complaint will be displayed for printing and record keeping purposes

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)
Business Name*

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

Vehicle Information
Make*

 
Model*

 
Year*

Motor Vehicle Repair Information
Date of Repair*   MM/DD/YYYY    
Repair Type*
Did you receive a copy of the written estimate before the work was performed? *  
Were the repairs the same ones you authorized? *  
Did you authorize any changes to the original estimate? *  
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