INSTRUCTIONS

COMPLAINT FORM

* Required fields

COMPANY CONTACT INFORMATION

Name of company complaint against:*
Name of person(s) you did business with:
Street Address:
City:
State:
Zip:
Mailing Address (if different from above):
City:
State:
Zip:

Company Contact Person (if any):
Phone Number:

YOUR CONTACT INFORMATION

Name:*
Phone Number (Day):
Phone Number (Night):
E-mail Address:
Street Address:*
City:*
State:*
Zip:*
Mailing Address (if different from above):
City:
State:
Zip:

Address of property in question (if different from above):

What type of transaction did you conduct with the party named above? (Example: loan, closing, etc.)*

When did the transaction occur? (If multiple dates, provide the first date here and clarify additional dates under the description section.)

Provide a concise description of the problem. (Remember to include who, what, when, where, why and how events transpired - see instuctions. You may attach additional pages as necessary. Please attach/send copies of all documents relevant to the complaint.) (2000 word limit)

of 2000 words max

OPTIONAL SECTION: What do you think will resolve this problem for you? (Be as specific as possible - see instructions.) (500 word limit)

of 500 words max

Do you have an attorney?: Yes No *

You may upload up to five supporting documents

File 1:	[Add]
File 2:	[Add]
File 3:	[Add]
File 4:	[Add]
File 5:	[Add]

Digital Signature

By checking this box I am certifying that the information provided above is accurate to the best of my knowledge.*