CONSUMER COMPLAINT FORM

A, .425, Office ohhelndiana AIIorneyGeneral

  

Case Number.11371974

 

To prevent delay, please be sure in complete hour sides or "us In Tull Please clearry or type no "01 Incrude ynur Social
Security Number an one [arm or In any accompanwng documents

1. YOUR INFORMATIU  2. WHO IS YOUR COMPLAINT 

[Mr I UMiss DMs, CID: 
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Address I
Wm 7

any A 1'm  Stanfile

ZIP jaw 22 Counly flmf/V

Phone '8 

EsmaIIanL QWH--mja'm


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A WHERE DIFTHE ARE COMPLAIHIHG Ariour TAKE (Check a I anre 7
memeIrrm'spIaceanusIness mMan 

 

7
'73. WHETI DID uccum

 

 

 

 

 

I El My name lntemeI/ermarl

place urousrnesnwork convenrran' elc) DByle!ephone APR 2 ZUIE I
Other 

5. WHAT wAs THE VERY FIRST cumAcT BETWEEN vou Arm THE rum? 7 Be "m 59 

 

Ell telephoned The firm

EH responded lo a TV/ramo ad
DA person came to my home

Waived Inlurmarran By e-maIl

renewed In the mall

\j I mm In Ine lrrm's pIace ur nusrness 
I renewed a can 1mm me nun
I responded In an olfer on (he Inremer
I responded (u a advemsemenI
Unmer

 

 

 

 

 

 

 

 

 

s. on vnu To mscufim FOLLOWING To THE Humor 7 7 7. WHAT WAS THE THANSACTIEN 
The nature and slams 01 your cmrIpIaInt and me name or me firm? busmess
Vaur name? as No My lamIly/nousehold
Your phone number? No CI My Tarrn
B. How DID vou fl
Dflasn We" Card DMedIIzaid CIPrIva|e Insurance 
DCheck Tnsraumenr Loan El Medicare Earner 

9. DID YOU SIGN ANY WRITTEN IF VES, PLEASE ATTACH A COPY OF THE AGREEMENT. Ms 
am ML 1 Seen was Mr mthI/IEIH/beeflv

For once Use Only. 

 

 

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Fran DYes

19i?0

12. HAVE YOU CONTACTED A PRIVATE ATTORNEY?

DYes

!BNo

13. HAVE YOU STARTED A COURl ACTION? IF YES, PLEASE ATTACH A COpy DF ALL COURT PAPERS.

DYes

BflO

14. HAVE YOU BEEN SUED DVER TIllS 'ISSUE? 'IF YES, 'PLEASE ATTACH A COpy OF ALL COURT PAPERS.

DYes

[)Mr

10. HAVE YOU COMPLAINED TO THE BUSINESS? (Check box when applicable)

When?

C}ltJf

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~ n r!bmafllJ h;tO~(TferJ ftJ (tVI

11. WITH WHAT OTHER AGENCY HAVE YOU FILED THIS COMPLAINT?

Action taken?

When?

15. DOLLAR AMOUNT ASSOCIA~D WITH YOUR LOSS, IF ANY. $

356. ()()

16. PLEASE DESCRIBE YOUR COMPLAINT IN DETAIL (ATTACH ADDITIONAL PAGES IF NECESSARy)

I Qr~

&tMr Com'P

IIWS 6~ lu 6~ ~

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rJe -hHlif1.l [etp1,

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18. CONSENT AND VERIFICATION
I affirm. under the penalties for perjury. that the foregoing representations are true. I consenlto the Consumer Protection Divisionobtaining or 

releasing any information in furtherance of the disposition of this complainl. I consent to therelease of informalion included in this complaint to 

other public agancies attempting to di$covcr ongoing fra"dul3nt patterns or pr<lclices and for the purpose of law enforcemeni. 

I understand at I should not include my Social'Security Number in any information submitted to lJle Consumer Protection Division. If I do 

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ey~0~~;;:t~~P)~;5

disclosure of my SOV1liiEumber in accordance with Indiana Code § 4-1-10-5(2).

four Signature

Date

WHAT WILL HAPPEN NOW? WHAT ELSE SHOULD YOU DO?
The Consumer Protection Division will send acopy of your complaint to the
respondent firm or licensed professional. This office cannot disclose your complaint 

against a licensed professional to the public unless this office files adisciplinary 

action against the licensed professional. This office repnesents the State of Indiana 

and is limited in the remedies rt can pursue. You may be entitled to compensation 

or other rights that we cannot pursue for you. In addition to filing this complain~ you 

may want to consider contacting a private attomey or your local small claims court.

MAIL COMPLETED FORMS TO:
Attorney General Greg Zoeller 

Consumer Protection Division 

Government Center South, 5'" floor 

302 West Washington Street 

Indianapolis. IN 46204 

PH : 317-232-6330. FAX: 317-233-4393
www.lndianaConsumer.com
Rev.OJ.09