1a.*First Name:    1b.Middle Initial: 
1c.*Last Name: 

3a.*Contact Name (for entity):
3b. Post Office Box Number:
3c. Street Address: * Either Street Address OR Post Office Box is required
3d.*City:
3e.*State: Press Arrow to Choose Alabama Alaska American Somoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington District of Columbia West Virginia Wisconsin Wyoming     3f.*Zip Code:
3g. Your E-Mail Address:

5a. Your Relationship with the complainant:
5b. Your First Name:   
5c. Your Last Name:
5d. Your Daytime Telephone Number :  ()   -      Extension:
5e. Your Mailing Address:
        Post Office Box Number:
        Street Address:
5f. Your City:
5g. Your State: Press Arrow to Choose Alabama Alaska American Somoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington District of Columbia West Virginia Wisconsin Wyoming     5h. Your Zip Code:

6a.* If your complaint involves Cellular Telephone, Paging, or other wireless services: (check here)
Accessibility by persons with disabilities to telecommunications services
Billing - Airtime Charges
Billing - Roaming
Billing - Service Plan Rate
Carrier Marketing & Advertising
Contract - Early Termination
Community/Regional Dead Spots (where there is no signal)
Premature Dropped Calls
Network Busy Signal
Other -- the subject of my complaint is not listed above.

OR

If your complaint involves Residential/Business Telephone or other wireline services: (check here)
Accessibility by persons with disabilities to telecommunications services
Telephone Company Marketing & Advertising
Cramming
International Call Rates
Operator Service Provider Rates
Rates for Interstate Telecommunications Services
Unsolicited Telephone Marketing
Unsolicited Telephone Marketing - telemarketer did not place me on their do-not-call list
Unsolicited advertisement sent to a facsimile machine
Other -- the subject of my complaint is not listed above.

6d_1.*()   -	6d_2.  ()   -
6d_3.  ()   -	6d_4.  ()   -
6d_5.  ()   -	6d_6.  ()   -

Yes    No (If yes, complete the following information:)

Company(ies) Name, telephone number and representative(s) number you spoke with:
7a. Company Name:
      Telephone Number: ()   -           Extension:
      Date: (Format: MM/DD/YYYY)

7b. Company Name:
      Telephone Number: ()   -         Extension:
      Date: (Format: MM/DD/YYYY)

8a. Have you paid any of the disputed charges? Yes   No
8b. Did the billing company adjust or refund the disputed charges? Yes   No
8c. If yes to either question, what is the amount of the adjustment or refund?

• account number(s) involved with your complaint if that number is different than your telephone number;
• date(s) of the telephone bill involved with your complaint;
• for Telephone Consumer Protection Act violations such as: unsolicited telephone call or an unsolicited advertisement sent to your fax machine, failure to implement a do-not-call request, etc., you must provide the date and time of incident and for faxes, a copy of the received, faxed document;
• the resolution you are seeking. (To better assist you, please send a copy of the bill(s) along with this form)

Yes   No
(If yes, we will contact you if we need additional information about your complaint.)

    

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