Office of Consumer Protection Complaint Form

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Consumer Complaint Form
downloadable version
Online Complaint Form

* Indicates Required Field

Complaint Reported By:
Last Name: , First Name: (Your name will be used as your case identifier/tracker.)
Street Address:
City: , State: ZIP Code:
Telephone Number(s): Home: Daytime:
E-Mail Address:
For statistical and informational purposes only, your age:

Complaint Reported Against:
Business Name:
Street Address:
City: , State: ZIP Code:
Telephone Number(s):

1. Nature of Complaint
Advertising	Direct Mail/Sweepstakes	Stocks/Securities
Automotive	Furniture	Telecommunications
Automotive Repairs	Health Club	Telemarketing
Banking	Home Repair	Used Car Lemon Law
Bingo/Raffle	Internet/Cyberspace	Warranty
Charity	New Car Lemon Law	Wheelchair Lemon Law
Credit Card	Professional Service	Weighing/Measuring Devices
Other, please specify

2. If your complaint involves a motor vehicle, please provide the following information. If your complaint does not involve a motor vehicle, please skip to the next question.
a. New or used b. Leased or purchased
c. Purchase price d. Current mileage
e. Date of purchase please choose one:
f. Make: Model: Year:

3. Name of the company with which you dealt:

4. Name and title of company agents or employees with whom you dealt:

5. Do you have any complaint-related contracts, bills, receipts, canceled checks, correspondence or any other documents you feel are related to your complaint?
Yes No

If the answer to question 5 above is "Yes," you will be required to forward readable copies of any complaint-related contracts, bills, receipts, canceled checks, correspondence or any other documents relating to your complaint to the Division of Consumer Affairs, Office of Consumer Protection, 124 Halsey Street, PO Box 45025, Newark, N.J. 07101. The Division will not initiate an investigation of your complaint until it has received legible copies of all of the documents you intend to submit as part of the evidence to support your complaint. Due to the fact that your name will be used as your case identifier, please be sure to write your name in the upper left-hand corner of every document that you submit to the Division of Consumer Affairs. Reminder: Retain the original document(s) and send only photostats of these papers.

6. Describe the facts of your complaint in the order in which they happened.

7. The amount of loss involved in this complaint:

By submitting this complaint form, I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment. In addition, I authorize the New Jersey Division of Consumer Affairs to send this complaint form to the company or to interested parties and to use the information in any way that is necessary.


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Consumer Complaint Form downloadable version Online Complaint Form

Consumer Complaint Form
downloadable version
Online Complaint Form