Consumer Investigation Request

* Salutation:
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Mr., Mrs., Ms., etc.

* First Name:
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Middle Initial:
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* Last Name:
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* Address Line 1:
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Address Line 2:
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Apt.,Ste.,etc.

* City:
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* State:
Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska Nevada New Hampshire New Jersey New Mexico New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming State is required

* Zip Code:
Consumer Zip Code is required Zip Code is invalid

* County:
- select - _Out-of-State Allen Anderson Atchison Barber Barton Bourbon Brown Butler Chase Chautauqua Cherokee Cheyenne Clark Clay Cloud Coffey Comanche Cowley Crawford Decatur Dickinson Doniphan Douglas Edwards Elk Ellis Ellsworth Finney Ford Franklin Geary Gove Graham Grant Gray Greeley Greenwood Hamilton Harper Harvey Haskell Hodgeman Jackson Jefferson Jewell Johnson Kearny Kingman Kiowa Labette Lane Leavenworth Lincoln Linn Logan Lyon Marion Marshall Mcpherson Meade Miami Mitchell Montgomery Morris Morton Nemaha Neosho Ness Norton Osage Osborne Ottawa Pawnee Phillips Pottawatomie Pratt Rawlins Reno Republic Rice Riley Rooks Rush Russell Saline Scott Sedgwick Seward Shawnee Sheridan Sherman Smith Stafford Stanton Stevens Sumner Thomas Trego Wabaunsee Wallace Washington Wichita Wilson Woodson Wyandotte County is required

* Daytime Phone Number:
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(XXX) XXX-XXXX

* Email Address:
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I am (mark all that apply):

Over age 60

Partially disabled

Totally disabled

Illiterate

Non-English speaking

A veteran or surviving spouse of a veteran

A member of the military

An immediate family member of a member of the military

Company Name:
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Name of Salesperson or Contact Person:
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Company Address:
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City:
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State:
- select - Alaska Alabama Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska Nevada New Hampshire New Jersey New Mexico New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming

Zip Code:
Zip Code is invalid

Company Phone Number:
Phone Number is invalid
(XXX) XXX-XXXX

Company Email Address:
Email Address is invalid

Company Website:
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If this was an online transaction, please provide the website address.

Date of Transaction:
Date of Transaction is invalid
MM/DD/YYYY

County/Place of Transaction:
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Please describe the transaction in chronological order:
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Did you sign a contract?:

Yes

No

Did you have a verbal agreement?:

Yes

No

Product or service involved:
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Amount paid: Do not include '$'
Amount Paid is invalid

Paid by:
- select month - Cash Check Credit Card Loan Direct Deposit/Transfer Gift Card Western Union MoneyGram Other

Describe the first contact between you and the company:

Salesperson came to my home

I telephoned the company

I responded to a radio/TV ad or direct mailing

I went to the company's place of business

I received a telephone call from the company

Other

Where did the transaction take place?:

Over the phone

At my home

At the company's place of business

By mail

On the Internet

Other

How could this harm be remedied?:

Refund

Product Delivery

Service Performed

Other

Refund Amount/Service Requested:
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If requesting a refund, please specify the amount. If you are requesting a service be performed, please specify the service.

Have you contacted the company?:

Yes

No

Describe the result, or explain why you have not contacted the company:
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Have you filed a complaint with the Better Business Bureau or any other agencies?:

Yes

No

Do you know of other consumers who have had similar experiences with this company?:

Yes

No

If you are being represented by an attorney regarding this matter, please list the attorney's name, address and telephone number:
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Has legal action been taken by you or against you regarding this transaction?:

Yes

No

Are you considering filing a claim in small claims court?:

Yes

No

In filing this request, I understand and agree that the Attorney General and the Attorney General's Office staff are not my private attorneys, but instead represent the State of Kansas in enforcing laws designed to protect the public from deceptive and unconscionable business acts and practices. I understand that Kansas Law limits the period of time during which I may file any private legal action(s). I further understand and agree that the contents of this request may be forwarded to the business or person the request is directed against, may be forwarded to other appropriate agencies, and will become accessible to others under the Kansas Open Records Act. I hereby authorize any party to whom the Attorney General directs this complaint to release any and all information about this matter, including account information, to the Kansas Attorney General's Office. Finally, I declare and verify under penalty of perjury and the laws of Kansas that all of the foregoing is true and accurate to the best of my knowledge.

* Please certify your agreement to the above statement by typing your full name in the box below:
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