| Consumer Information |
| Name |
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| Address 1 |
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| Address 2 |
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| City |
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| State |
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| Zip |
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| Home Phone with Area Code |
A value is required.*required |
| Work Phone with Area Code |
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| E-mail |
A value is required.Invalid format.
*required |
| Age |
|
| Business’s Information |
| Name of Business |
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| Address 1 |
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| Address 2 |
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| City |
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| State |
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| Zip |
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| Phone with Area Code |
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Name of person you dealt with |
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Website or
Email Address |
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| What is your Complaint? |
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| Contact with Business |
| Have you complained to the business? |
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| If yes, where? |
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| What was the business’ response? |
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| Have you contacted another agency or attorney about this complaint? |
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| If yes, please list the name and address of the agency or attorney |
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| What action was taken by this agency or attorney? |
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| My complaint arises from a transaction involving a/an: |
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| First Contact with the Business |
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| If other please specify |
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| If you responded to solicitation in another language, which one? |
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Where did transaction take place? |
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| If other please specify |
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| Date(s) of transactions |
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| Did you sign a contract? |
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| How much did the company/individual ask you to pay? |
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| How much money is involved? |
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Where did you hear about the Texas Consumer Complaint Center? *required
Please select an item.
Please eleborate on how you heard about us (i.e. What newspaper, what tv channel, what public event)?
A value is required. |
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