Montgomery County, MD

Government

Office of Consumer Protection

OCP Complaint Application

Instructions:
1. Before submitting a complaint, please complain directly to the company. If the company does not resolve the issue, submit a complaint online.
2. Please complete the entire form. Required fields are marked with an asterisk (*).
3. Supporting documents are submitted separately. Send copies of any documents involved in the transaction (including advertisements, contracts, receipts, statements, the front and back of canceled checks, correspondence, warranties, etc.) by e-mail, fax or hard copy. Instructions are provided below. Include your case number on all correspondence.
4. Failure to submit paperwork may delay investigation of your complaint.
5. Do not send any original documents. We will not be responsible for originals.

* = Required Field

Consumer Information

Title

First Name*

Middle Name / Initial

Last Name *

Address *

Apt./Unit

City *

State *

Postal / Zip Code *

Country *

Telephone Day * Ext.

Telephone Evening Ext.

Telephone Cellular

Fax

Please check "Yes" to receive consumer alerts and news via email. * Yes
No

For statistical purposes, please tell us if you are 65+ years of age. * <65
65+
Decline

Individual/Merchant Information

Please search for Individual or Merchant and select it from the drop down. If you cannot find the Individual or Merchant (No Match Found), click the “Add New Individual/Merchant” button to add the new Individual or Merchant.

Individual or Merchant Name

Complaint Information

Describe your complaint. (Do not include sensitive personal data such as credit card numbers, bank account numbers, etc.) *

Transaction Type *

Payment Method*

Transaction Date

Did you sign a contract? If Yes, please mail in a copy of the contract. * Yes
No

Date First Complained To Business. If there are additional dates, please indicate in 'Describe your complaint...' above. *

Name of Person Contacted *

Title of Person Contacted:

Did s/he respond? * Yes
No

Is there a pending court action? * Yes
No

Have you submitted this matter to an attorney or another agency? * Yes
No

Refund Amount Requested/Estimated Value of Claim: *

What form of relief are you seeking? (Exchange, Repair, Money Back, etc.) *

How did you learn about us? *

Language Preference*

Electronic Signature Agreement

READ AND UNDERSTAND THE FOLLOWING BEFORE SIGNING BELOW:
Once we receive your complaint, it will be reviewed for jurisdiction and to determine the best course of action. If we determine that there is a more suitable agency to handle your dispute, we will make an appropriate referral and advise you in writing. Otherwise, your complaint will be assigned to an investigator. We will send you an acknowledgement letter providing the name and phone number of of your investigator, and the case number assigned to the complaint.

Please include your case number on any future correspondence you send to us.

I authorize the Office of Consumer Protection and/or its representative to make inquiries on my behalf, into any and all files or accounts that may be necessary to investigate the complaint I have filed with the agency. Further, I authorize the office of Consumer Protection to use and supply, on my behalf, any private information included in this document.

I understand that a copy of this form may be sent to the business against which I have filed this complaint. I understand that this complaint is a public document and is available for inspection by the public and the media.

I do solemnly declare and affirm under the penalties of perjury that the contents of my complaint are true and correct.

By entering your full name in the “Signature (Type your full name)” field, you are signing this Complaint Form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Complaint Form.

Signature (Type your full name): *

You will be able to upload supporting documents after you click the 'Submit' button below."