Prices & Consumer Affairs Division

Consumer Complaint Form

The information provided below will assist the Division in investigating your complaint.

Date of Complaint:

Consumer's Information

First Name:

Last Name:

Address:

Age (You must be 18 years or older to file a complaint)

Gender
Male Female

Telephone Number:

Email Address:

Identification Type:
Driver's License Social Security Number Medical Benefit Number

Identification Number:

Supplier's Information

Supplier's Business Type
Person Business

Name:

Address

Number:

Goods or Service Information

Goods or Service Type
Good Service

Date of payment:

Cost of Good / Service:

Name of Good/Service:

Brand Name: (If applicable)

Type of Purchase Agreement
Cash Layaway Hire Purchase Other

Other (If other option is selected)

Place of Storage for duration of complaint
Consumer Supplier Other

Other (If other option is selected)

Supplier's Compliance with Consumer Protection Act

Were you provided with a receipt?
Yes No

Were you provided with a Warranty?
Yes No

Were you provided with a written agreement?
Yes No

Do you have proof of purchase? (If No is selected please fill in reason below)
Yes No

Reason for not having proof of purchase:

Select all the options that were provided to you before payment?
Instructions Hazards Return Policy Conditions for Redress

Complainant Statement

Please state the problem that you have experienced with the Good/service:

Type of redress being sought?
Cash Refund Store Credit Exchange Repair

Supporting Documents

Please provide any supporting documents, such as a receipt of purchase. The sum of all files must be less than 7MB. (Accepts .PDF, .PNG, .JPG, .JPEG)

Declaration

Please check all the declaration boxes below if you agree.
I am willing to testify in any proceedings related to this complaint, if necessary.
I certify that the information provided above is true and accurate to the best of my knowledge and belief.

By submitting my complaint, I hereby authorize the Prices and Consumer Affairs Division to investigate it.