You must have JavaScript enabled to use this form. First Name Last Name Address City State Zip Code County Home Telephone Business Telephone Primary Provider of Service Service Provider Address Service Provider City/Town Service Provider Telephone Secondary Provider of Service Secondary Address Secondary City/Town Secondary Telephone Date of Transaction: How was the product purchased? - None --None-CashCheckCredit CardOther Amount Paid Did you sign a Contract: - None -YesNo Contract Details: Date Signed: Where Advertised: How was complaint submitted to service provider: - None -MailEmailTelephoneFaxIn Person The date complaint was submitted to service provider: Person Contacted: Title of Person Contacted: Has the matter been submitted to an agency or attorney: - None -YesNo If "yes" provide name and address. If "no" leave blank. Please describe court action if necessary: Manufacturer of product Product model or serial number Manufacturer Product Address Warranty Expiration Date Did business arrange financing: - None -YesNo If "yes" to financing provide name and address. If "no" leave blank. Describe your compaint: What form of relief are you seeking? (Ex:Exchange, Repair, Refund, Etc...) Who referred you to this office: In order to resolve your complaint, we may send a copy of this form to the person or firm about whom you are complaining. In filing this complaint, I understand that the Schenectady County Department of Consumer Affairs is not my private attorney, but represents the public in enforcing laws designed to protect the public from misleading or unlawful business practices. I also understand that if I have any questions concerning my legal rights or responsibilities, I should contact a private attorney. I have no objection to the contents of this complaint being forwarded to the business or person the complaint is directed against. The above complaint is true and accurate to the best of my knowledge. I also understand that any false statements made in this complaint are punishable as a Class A Misdemeanor under Section 175.30 and/or Section 210.45 of the Penal Law.
