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Consumer Complaint
SECTION 1: Your Information
Title
Mr.
Mrs.
Ms.
Last Name
*
First Name
*
M.I.
Mailing Address Line 1
*
Mailing Address Line 2
City
*
State
*
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
*
Country, if not US
Day Phone
*
Evening Phone
Mobile Phone
*
Fax Number
County of Residence
*
Email
*
SECTION 2: Compliant Information (complete any that apply to your complaint)
Year
*
Make
*
Model
*
VIN
*
Mileage
Date of Reposession
SECTION 3: Information About The Transaction
Where did the transaction take place?
At my home
At my workplace
By Mail
Over the phone
Via computer (website or email)
Trade show or hotel
Other
If other, please describe below
SECTION 4: Details of The Complaint
Please explain your complaint in detail...
SECTION 5: Confirmation
I confirm that the information provided is true and accurate to the best of my knowledge.
Security Code:
*