Free 46220.pdf - Indiana

VERIFIED COMPLAINT REQUESTING RESTITUTION FROM THE PRENEED CONSUMER PROTECTION FUND
State Form 46220 (10-93)

PLEASE COMPLETE BOTH SIDES OF THIS FORM. TYPE OR PRINT CLEARLY - PLEASE USE BLACK INK.

INDIANA STATE BOARD OF FUNERAL AND CEMETERY SERVICE Indiana Professional Licensing Agency 302 West Washington Street, Room E034 Indianapolis, Indiana 46204-2700 Telephone number: (317) - 232-2980 Fax number: (317)-232-2312

JURISDICTIONAL STATEMENT (Please read carefully) Our ability to investigate consumer complaints is established and limited by the Indiana General Assembly. Every complaint received by the Indiana State Board of Funeral and Cemetery Service is reviewed to determine whether or not we have jurisdiction over the dispute. If the Indiana State Board of Funeral and Cemetery Service cannot take action on your complaint, it will be referred to the appropriate State agency, if any, for action and you will be notified as to why we are unable to assist you. PERSONAL INFORMATION
Name of complainant (Mr., Mrs., Miss, Ms.)

Address (number and street, city, state, ZIP code) Telephone number (day) ( ) Telephone number (evening) ( )

County

RESPONDENT INFORMATION (Your complaint is against)
Name

Address (number and street, city, state, ZIP code) Telephone number ( Type of business Type of product or service )

County

TRANSACTION INFORMATION
Date of transaction, sale, incident, or service (month, day, year) Name of salesperson, agent or professional

How did you come into contact with this person or company? (check one) A salesperson contacted me: By telephone At my door I answered a mail order advertisement I visited an office or place of business

Other (Please describe) I made this transaction for:

Briefly describe your complaint (Use the back side of this form for detailed description).

Did you sign a contract? (Attach a copy of the contract, if available) Yes Have you complained directly to the respondent? (Describe) No

Did you pay with credit card? Yes No

What result are you seeking?

OTHER INFORMATION
Have you filed a complaint with any other agencies? (Describe) Yes No

Have you contacted a private attorney? (If Yes, give his or her name, address and telephone number) Yes No How were you referred to this office?

Has a lawsuit been filed against you or on your behalf? Yes No

DO NOT WRITE BELOW THIS LINE
Date received File number Disposition

(Continued on the reverse side)

COMPLETE DESCRIPTION OF TRANSACTION (Attach additional pages if necessary. IMPORTANT: Attach copies of the contract, cancelled check(s), receipt(s), and any other document(s) related to you complaint.)

THIS SECTION MUST BE SIGNED VERIFIED CERTIFICATION I hereby certify, under the penalties of perjury, that the information on this form is accurate and complete to the best of my knowledge and belief. I authorize the Indiana State Board of Funeral and Cemetery Service to use this information in any manner it deems necessary.
Signature of complainant Date (month, day, year)