MA Consumer Complaint Form shell

Consumer Complaint and Information Section
200 Portland Street
Boston, MA 02114

Consumer Information:
Name:
Address:
City/State/Zip:
Daytime Phone:

Business/Complaint Against:
Name:
Address:
City/State/Zip:
Phone: (617) 242 8721

You are not required to answer but, are you 65 years or older? NO

Product/service involved:
Cost of product/service:
Amount paid to date:
Date of transaction:
Was a contract signed?
How did you pay for product?
Was product/service advertised?
Have you complained directly to the company:

What resolution do you seek?

CONFIDENTIALITY

Under most circumstances, the text of your complaint will be considered a public record, a copy of which is available to any member of the public upon request. In response to such requests, this Office generally will not disclose your name, address, phone number, or any other information that identifies you and will not disclose this form in response to any request that specifically seeks the complaint submitted by you. Your record in its entirety may, however, be disclosed to law enforcement and regulatory agencies who may assist in resolving your complaint.

Signature: _________________________________________________

Date: ______________________

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