= Required Information

What is your Complaint Regarding

What is your complaint regarding?	(loading...)

Your Information

Salutation
First Name
Middle Name
Last Name
Suffix
Your Company Name (if applicable)
Address
Address Type
City
State	(loading...)
County
ZipCode
Age
Your Daytime Phone Number
Are you or your spouse active military?
Email (if no email leave blank)
May we contact you by email? If yes, we will not contact you by regular mail.	(loading...)

Consent and Verification

Do you consent to disclosing the following information to the public?

Nature of complaint and firm's name

Yes

Your name

Yes

Your phone number

Yes

I affirm, under the penalties for perjury, that the foregoing representations are true. I consent to the Consumer Protection Division obtaining or releasing any information in furtherance of the disposition of this complaint. I consent to the release of information included in this complaint to other public agencies attempting to discover ongoing fraudulent patterns or practices and for the purpose of law enforcement. I understand that I should not include my Social Security Number in any information submitted to the Consumer Protection Division. If I do provide my Social Security Number, I expressly consent to the disclosure of my Social Security Number in accordance with Indiana Code § 4-1-10-5(2).

Your Name

Date

[ 11/5/2024 ]

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