Consumer Protection Complaint Form

Use this form to request assistance from this Department. Attach COPIES of appropriate documentation (correspondence, invoices, contracts, and related information). This material is necessary in order to attempt resolution of your complaint.

You may also download this form.

Consumer Information

Your Name

Address - Number and Street

City, State, Zip

Cell

Business

Fax

Email Address

Your address, if different from above

Amount Disputed

Vendor Information

Name of person or firm

Address - Number and Street

City, State, Zip

Telephone (including area code)

Fax

Your account or invoice number

Email Address

Name of person(s) you dealt with at facility

Date of Transaction

Amount of Transaction

Nature of complaint or problem

The resolution sought

Exchange

Refund

Repair

Deposit Returned

Other restitution

Have you complained to any of the following?

Company

Date Contacted

Name

Attorney

Date Contacted

Name

Other

Date Contacted

Name

Supporting documentation must be attached before complaint can be processed.

Submit documentation as a single pdf or jpg image

Documentation

One file only.
5 MB limit.
Allowed types: jpg, jpeg, png, pdf.

I understand that Erie County Division of Consumer Protection may send a copy of this form and any or all, of the enclosed information to the vendor or another agency for resolution.
I hereby certify that the information I have given is true and complete to the best of my knowledge.
I understand that Erie County Division of Consumer Protection complies with the Freedom of Information Law.
I Authorize the Erie County Division of Consumer Protection to act on my behalf in the mediation of this complaint.

I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.

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

Date