Consumer Investigation Request

* Salutation:

Mr., Mrs., Ms., etc.

* First Name:

Middle Initial:

* Last Name:

* Address Line 1:

Address Line 2:

Apt.,Ste.,etc.

* City:

* 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

* Zip Code:

* 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

* Daytime Phone Number:

(XXX) XXX-XXXX

* Email Address:

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:

Name of Salesperson or Contact Person:

Company Address:

City:

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:

Company Phone Number:

(XXX) XXX-XXXX

Company Email Address:

Company Website:

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

Date of Transaction:
 
MM/DD/YYYY

County/Place of Transaction:

Please describe the transaction in chronological order:

Did you sign a contract?:
Yes
No

Did you have a verbal agreement?:
Yes
No

Product or service involved:

Amount paid: Do not include '$'
 

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:

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:

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:

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:

* Type the characters you see in the image below: