Business Response Form

Instructions: Complete and submit this form.

A COPY OF THIS REPLY WILL BE SENT TO THE CONSUMER

You may also download this form to complete and return via standard mail, email, or fax.

Name of Consumer

Date Issued

Legal Name of Company

Executive Office Address

Name of President/Member/Sole Proprietor or Owner

Name of person to contact for additional information

Telephone

Response to complaint

Enclose copies of documents supporting your position.

Maximum 5 files.
5 MB limit.
Allowed types: jpg, jpeg, png, pdf.

In order to resolve this matter, we offer to

I understand that any false statements made on this form are punishable as a Class A Misdemeanor under §175.30 and/or §210.45 of the Penal Law.

Electronic Signature Agreement

By checking the "I agree" box below, you agree and acknowledge that 1) your form will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

I Agree

Name

Title

Date