ADVANCED COMPLAINT FORM

Advanced complaint form g-69

Consumer Complaint Form To submit your complaint: 1. Fill out this form as completely as possible, sign it and mail the signed original (not a copy) to the Office of Consumer Protection. Keep a copy for your own records. 2. Enclose photocopies of all documents relevant to your complaint, such as receipts, warranties, both sides of cancelled checks, contracts, etc. In this case, do not send originals.

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

ID# *

Email *

Phone Number *

Home Department *

Complaint Against

Name *

First

Last

Email *

Phone Number *

Department *

ID# or DID# *

If your complaint relates to false advertising or deceptive trade practices, indicate when and where the product or service was advertised. (If possible, attach a copy of the advertisement.) *

Was a contract signed? *

Yes ( ) – please attach a copy No ( )

Was a warranty issued? *

Yes ( ) – please attach a copy. No ( )

Financial Institution Involved, if any: *

Have you contacted the party complained of? *

yes no

Fully explain the nature of your complaint. Describe events in the order in which they occurred. Use additional pages if necessary *

State the relief you desire, i.e. refund, repair, etc.: *

NOTE: If you desire legal advice, we suggest you contact a private attorney to handle your complaint.

I understand that:
• Bios Kosmos Church has full discretion concerning its acceptance, investigation and resolution of this complaint;
• Bios Kosmos Church cannot act as my attorney; and
• no attorney/client relationship is established as a result of any activities undertaken on my behalf.

I hereby:
• affirm that this complaint is true and correct to the best of my knowledge; and
• authorize the use of my name and this complaint in investigating the company or individual complained of

Date *

Signed *

Submit

Advanced complaint form g-69

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