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On Line Consumer Complaint Form
Nassau County residents can use the online form below to file a complaint against any vendor regulated by the Nassau County Office of Consumer Affairs. You can also download the form (PDF format) and then print it, fill it out and mail the completed form along with all supporting documentation to the Nassau County Office of Consumer Affairs 200 County Seat Dr. Mineola, NY 11501.
THIS OFFICE IS SUBJECT TO THE FREEDOM OF INFORMATION LAW
Consumer Complaint Form
Complaint By:
* First Name * Last Name
* Address
* City * State * Zip Code
Email * Daytime Phone Number
(555-555-5555)
Complaint File Against:
* Vendor Name Business Owner
* Vendor Address * Vendor Daytime
Phone Number
(555-555-5555)
* City * State * Zip Code
Please answer the following questions regarding your complaint:
* Complaint against
* Date of contract or purchase(MM/DD/YYYY)
Date you complained to the company(MM/DD/YYYY)
Name of the person you complained to
Payment Type Cash Check Money Order Credit Card
Amount $
* Have you referred this complaint to another Agency or small Claim Court:  Yes No
 * WHAT RESOLUTION WOULD YOU CONSIDER SATISFACTORY:  
 * PROVIDE SPECIFIC DETAILS AND FACT OF THE COMPLAINT IN THE ORDER IN WHICH THEY OCCURED:
 
* I certify, subject to penalties of perjury, that all the statements made in this complaint, including statements made in the supporting documentation, have been examined by me and to the best of my knowledge, information and belief are true and correct. By choosing to submit this form electronically, I certify and agree that by entering my name in the space below, I bind and legally obligate myself to the same as I would by signing my name on a printed paper version of this form and understand that this constitutes my electronic signature.
* Signature ** A copy of this form may be forwarded to the VENDOR by the Office of Consumer Affairs.
* Date