Department of Consumer Protection Complaint Form


Complete the form with as much information as possible and click the "Submit Complaint" button at the bottom of the page. ( *= required field). If you prefer to submit a written complaint, download this form and mail it to the address on the form. Our Spanish speaking residents may print a paper form to complete: Formulario de Queja del Consumidor. The completed form may be mailed or faxed to our office. Our address and phone numbers are found on the form. En este momento, nuestros residentes de habla español pueden imprimir y llenar en papel si tienen una queja usando el Formulario de Queja del Consumidor. El formulario completado puede ser enviado por correo o fax a nuestra oficina. Nuestra dirección y números aparecen en el formulario.
First Name:*
Middle Initial:
Last Name:*
Street Address:*
City:*
State:*	Zip Code:*
Daytime Phone:*	Please include the area code.If you do not have a phone, please indicate, "no phone"
Email Address:

Complete the following information about the company against which you are submitting a complaint:
Company Name:*
Street Address:
Additional Address:
City:*
State:*	Zip Code:
Telephone Number:	Please include the area code
Internet Address:
Internet Email:
Product or Service in Dispute:*
Is the service or product for a Home Improvement?	Click in the box if your answer is "Yes."
Date of Transaction:*	Example: 1/2/00
Name of Company Representative:
Title of Representative:	Ex: Sales Associate
Total cost of product or service:*	Example:$1,078.76
Amount you paid:	Example:$545.76
Date you contacted the company concerning your complaint?	Example: 1/2/00
Name of person contacted:
Describe the nature of your complaint:* (max. 4000 chars.)
What resolution are you seeking?*
For security purposes, please answer this question before you click “Submit”.* 6 + 3?
You must provide supporting documentation: contracts, correspondence, receipts,etc. Documents may be faxed to 914-995-3115 or email to conpro@westchestercountyny.gov. Reference your complaint number on all pages.
I Hereby Certify that the information I have given is true and complete to the best of my knowledge. I understand that Westchester County Department of Consumer Protection complies with the Freedom of Information Law. I Authorize the Westchester County Department of Consumer Protection to act on my behalf in the mediation of this complaint.