CT Attorney General: e-Complaint Form

Salutation:

First Name:

Last Name:

If business related, enter your company name:

Street Address:

City/Town:

State:

Zip Code:

Phone:

Phone Extension: (Optional)

Email Address: Proper format "john_doe@gmail.com" Provide a vaild email address to receive a confirmation receipt.

I am a senior citizen (over 60)

Have you ever served in the U.S. Military?

Yes No

If yes, do you authorize the Attorney General's Office to share your contact information and/or this complaint and any attached documents with the Connecticut Department of Veterans Affairs (DVA) ?

Yes No

If yes, do you want to receive information from the DVA regarding potential eligibility for veterans benefits?

Yes No

Who is your complaint against?

Name Of Business Entity Or Provider Of Services:

Salutation:

Complainee First Name:

Complainee Last Name:

Street Address:

City/Town:

State:

Zip Code:

Phone Number:

Extension: (Optional)

Email Address: Proper format "john_doe@example.com"

Business Website:

Complaint Subject:

Describe Your Complaint

Date of transaction or incident: (Example: 01/01/1990)

Briefly Describe your complaint: (Note: 1000 characters maximum)

Number of characters remaining:

Is your complaint about goods or services?

Yes No

Is your complaint about Robocalls or Phone Fraud?

Yes No

Robocalls or Phone Fraud

If you wish to submit audio recordings or voicemails, please email them to AG.ConsProt@ct.gov

Other supporting documents, such as robocall log forms, screenshots, or call transcripts can be attached in the Supporting Documents Upload Section of this complaint.

Date and Time of Call: (Example: 01/01/1990 12:00 am)

Type of Call? Recording Live Caller

Calling Number: (Scammer's Number)

Dialed Number: (Your Number)

Number of Calls: (Optional)

Did you make a payment? Yes No

If yes, how did you pay?:

Payment Amount: (Do not include $ sign.)

Goods Or Services Details

Did you make a payment? Yes No

If yes, how did you pay?:

Cost of product or service: (Do not include $ sign.)

Did you sign a contract? Yes No

If yes, where contract was signed:

Date signed: (Example: 01/01/1990)

Was product or service advertised? Yes No

If yes, where was it advertised:

Date advertised: (Example: 01/01/1990)

Action Taken By You:

Have you previously contacted the CT Attorney General Office or other State or Federal Agencies about this matter?

Yes No

If yes, please list the most recent dates and names of previously contacted State or Federal Agencies.

Contact Date:

Name of State or Federal Agency:

Have you contacted a private attorney regarding this matter?

Yes No

If yes, provide attorney Name:

Attorney Phone:

Attorney Email Address:

Is court action or other legal proceeding pending?

Yes No

If yes, provide Docket no.:

Do you want to upload supporting documents? upload files

Yes No

Supporting Documents Upload ...

File upload instructions:

Total number of files you can upload is 3
Maximum file size limit is 2MB (2000 KB)
Upload document files of type .docx, .doc, .txt and .pdf
Upload image files of type .jpg, .jpeg, .tif, tiff, .png and .bmp
To reset the attached file(s), you can always select the radio button "No" above.
All rules above must be applied for a successful upload. If one file fails, re-select all files again.

Please do NOT include financial account numbers, credit or debit card numbers, your social security number, etc.,
or other sensitive personal identifying information. We will contact you if we need any of this information.

If we need additional documents from you, we will:

Contact you directly
Tell you what documents we need, and
Arrange for you to provide it to us in a more secure manner.

Select the file(s) by clicking the button below.

File 1 size (MB)

File 2 size (MB)

File 3 size (MB)

If you select a wrong file type or size you can always click the button again to choose a different file that meets the upload requirements..

Declaration and Signature

In filing this complaint, I acknowledge that the Attorney General does not represent me individually, but represents the State of Connecticut in enforcing laws designed to protect the public from deceptive or unfair practices. I understand that all questions concerning my legal rights or responsibilities, should be directed to the private attorney of my choosing.

I acknowledge that information submitted to the Office of the Attorney General may be considered public information subject to disclosure under the Connecticut Freedom Of Information Act, Connecticut General Statutes Section 1-200 et. seq.

I understand that the Attorney General’s Office may contact the person or business that is the subject of the complaint. I authorize the Attorney General’s Office to provide a copy of this completed form and any attached documents to all necessary parties including the person or business that is subject of the complaint.

Signed By:

By typing my full name above and checking this box, I certify that the above complaint is true and accurate to the best of my knowledge and that any documents attached are true and accurate copies of original, and I adopt this as my online signature.

Captcha vertification is required! Check the box below and follow the instructions.

Attorney General William Tong

e-Complaint Form

Your Information

Who is your complaint against?

Describe Your Complaint

Robocalls or Phone Fraud

Goods Or Services Details

Action Taken By You:

Supporting Documents Upload ...

Declaration and Signature