Free Print File - Michigan


File Size: 20.2 kB
Pages: 2
File Format: PDF
State: Michigan
Category: Government
Author: scottb1
Word Count: 689 Words, 4,346 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dleg.state.mi.us/bcsc/forms/enf/lce-992.pdf

Download Print File ( 20.2 kB)


Preview Print File
BCS/LCE-992 (01/08) Department of Labor & Economic Growth Bureau of Commercial Services - Enforcement Division P.O. Box 30018, Lansing, MI 48909 Telephone: (517) 241-9202

Complaint Number-For Office Use Only

STATEMENT OF COMPLAINT
INSTRUCTIONS TO THE COMPLAINANT: Please type or print legibly in ink. Read both sides of this form carefully before completing. Be sure to sign and date the back of this form. This Division has jurisdiction in only certain matters involving consumers and licensees in the area of occupational professions. It is suggested that you first contact the person or firm about whom you have a complaint to see if the matter can be settled. If this has been unsuccessful, you may want to consult an attorney to determine your civil options, file an action in Small Claims Court, or contact your Prosecutor. These may be done in conjunction with or instead of filing a complaint with this Department.

YOUR COMPLAINT IS AGAINST
1. Name of Licensee (Company) 7. Name

INFORMATION ABOUT YOU

2. Address (Number and Street)

8. Address (Number and Street)

3. City, State

Zip Code

9. City, State

Zip Code

4. Telephone Number ( )

10. Telephone Number Day ( ) Evening ( )

5. Name of Person You Dealt With

11. Are you willing to testify in a hearing? Yes

No

6. License Number (If known)

12. Mediation may be available to quickly resolve the complaint. Are you willing to meet with a Department conferee and the licensee to mediate the complaint? Yes No

13. Here is a list of the professions we regulate. Indicate which profession your complaint is against. Alarm System Contractors Architect Auctioneers Barber/Barber Shop Boxing Carnival Ride Cemetery Collection Agency Community Planner Cosmetologist CPA/CPA Firm Cosmetology School/Shop Electrologist/Manicurist Employment Agency Engineer Forester Hearing Aid Dealer Immigration Clerical Assistants Interior Designers Land Sales Land Surveyor Landscape Architect Yes No Mortician or Funeral Home Ocularists Pre-Paid Funerals Private Detectives Polygraph Examiner Real Estate Agent/Company Real Estate Appraiser Security Guard Agencies Ski Area Vehicle Protection Warranty

14. Have you contacted the above named person or company in writing about your complaint? If yes, what was the result?

15. Did you file a claim with any other agency, or start civil or criminal action? If yes, where? What is the current status of that claim? 16. What do you want the person or company named above to do to resolve the complaint? Case Number

Yes

No

For Office Use Only

BCS/LCE-992 (06/07) Page 2 of 2

17. Identify financial losses, if any (Itemize on a separate sheet of paper): 18. DETAILS OF YOUR COMPLAINT. Briefly explain your complaint. Attach additional sheets, if necessary, to clearly document the violations which you believe have occurred.

19. Attach copies of the following documents as applicable to support your complaint. Failure to do so will cause unnecessary delays. Check below which documents you have enclosed. Listing Agreement Offer to Purchase Closing Statement Canceled Checks, Receipts Claim Form Land Contract Advertisements Plats, plans, other specifications Property Report Land Survey Legal Property Description Contract for Service

You may be asked to provide other documents at a later date to support your complaint. Do Not Send At This Time. However, you may want to save these, in case they are needed in the future.
I give my permission for the release of all relevant information and records to the Department of Labor & Economic Growth for its use in the review of my complaint.

YOUR SIGNATURE

DATE OF SIGNATURE

This form is authorized by PA 368 of 1978, PA 299 of 1980, PA 251 of 1968, PA 199 of 1962, PA 225 of 1966, PA 295 of 1972, PA 255 of 1986, PA 132 of 1982, PA 87 of 1855, and PA 12 of 1869, each as amended. It is designed to assist you in outlining a complaint completely and concisely, but there is no penalty for failing to submit it.

For Office Use Only

The Department of Labor & Economic Growth will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.