Consumer Protection Credit Card Surcharge Complaint Form

Are you a resident of Erie County, New York?

Yes

Is the business you have a complaint against in Erie County, New York?

Yes

Use this form to request assistance from the Erie County Division of Consumer Protection. Attach COPIES of appropriate documentation (receipts, invoices, pictures, and related information). This material is necessary in order to attempt resolution of your complaint.

Consumer Information

Your Name

Address - Number and Street

City, State, Zip

Home/Cell Phone Number (including area code)

Work Phone Number (including area code)

Fax Number (including area code)

Email Address

Your address, if different from above

Business Information

Name of Business/Subject of the Complaint

Business Address - Number and Street

City, State, Zip

Business Phone Number (including area code)

Fax Number (including area code)

Business Email Address

Name of person(s) you dealt with at business

Date of Transaction

Amount of Transaction

Amount of Surcharge

Method of Payment

How was the price(s) listed or displayed?

Nature of complaint or problem

Do you have a copy of the itemized receipt and proof of purchase?

Yes

Other

The resolution sought

Refund

Report only

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.

In filing this complaint, I understand that:

The Erie County Division of Consumer Protection is not my private attorney, but represents the public in enforcing laws designed to protect the public from misleading or unlawful business practices. My filing this complaint does not mean that the Erie County Division of Consumer Protection has initiated a lawsuit or proceeding on my behalf or that it will do so.

The Erie County Division of Consumer Protection cannot give me legal advice or represent me in court. If I have any questions concerning my legal rights or responsibilities, I should contact a private attorney.

In order to resolve my complaint, the Erie County Division of Consumer Protection may send a copy of my complaint and any documents I provide to the person or business about whom I am complaining and I authorize that person or business to release information concerning my complaint to the Erie County Division of Consumer Protection.

The Erie County Division of Consumer Protection works with other state, local and federal government agencies to investigate complaints and coordinate law enforcement and may also share my complaint with them. In addition, the Erie County Division of Consumer Protection may use information from my complaint in legal proceedings to establish violations of law.

Any false statement made in this complaint are punishable as crimes, including under Section 175 and/or Section 210 of the Penal Law.

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

Thank you for visiting the Division of Consumer Protection website for Erie County, NY.

Your complaint may be outside of the jurisdiction for the Erie County Division of Consumer Protection. Please refer to your local consumer protection agency for assistance.

If you are a resident in New York State, you may contact the New York State Division of Consumer Protection Consumer Helpline at (800) 697-1220 or visit their website to file a complaint online.

Please contact our office at 716-858-1987 if you have additional questions or concerns.