Enclosed is the Complaint Form you requested. Consumer

OFFICE HOURS MONDAY – FRIDAY 9 AM – 3 PM
PLEASE READ ALL SHEETS CAREFULLY
Enclosed is the Complaint Form you requested. Consumer Assistance Council (CAC), is a non-profit volunteer
organization that serves to educate & assist consumers in trying to resolve complaints with merchants. An
experienced volunteer mediator will mediate your complaint through an informal process in an effort to reach a
mutually agreeable settlement . CAC is NOT A LEGAL ASSISTANCE AGENCY & CAN NOT PROVIDE
LEGAL ADVICE OR REPRESENTATION. WE DO NOT HAVE ENFORCEMENT POWERS.
COMPLAINT PROCESS- HOW WE WORK
When your completed Complaint Form is received, it will be assigned to a volunteer mediator who will handle your
complaint. A letter will be sent to the business requesting that they respond within 14 days. If a reply is not
received, the volunteer mediator will attempt additional follow up.
You will receive a letter from us indicating your CASE NUMBER, (please keep this case number for future
reference when you contact the office) and noting the name of your volunteer mediator and the day he/she
volunteers, should you need to speak with them. Please keep your Volunteer Mediator informed of any new
developments in your case.
Please note that the names of all parties are submitted to the Attorney General's Office so that agency may
effectively monitor any emerging patterns relative to your complaint. The Attorney General may then be in a
position to intervene in those cases that affect a larger segment of the population.
If you h ave questions concerning the specific application or interpretation of the law, you should consult a private
attorney. If you do not have an attorney, you can call the following Bar Association for your area:
BARNSTABLE COUNTY
3217 Main Street
PO Box 586
Barnstable, MA 02630
BRISTOL COUNTY
448 County Street
New Bedford, MA 02740-5399
If you cannot afford an attorney you may be eligible for assistance through your local Legal Services Office.
Thank you for bringing this matter to our attention. We hope we can provide assistance to you.
Kimberly Denis
Executive Director
149 MAIN STREET
HYANNIS, MA 02601
E-MAIL: [email protected]
www.consumercouncil.com
TELEPHONE: 508-771-0700
FAX: 508-771-3011
800-867-0701
CONSUMER COMPLAINT FORM - fill out on your PC
CONSUMER
CONSUMER: Please supply information requested below. TYPE info. -then print.
Name: __________________________________________________
Address: ________________________________________________
City/State/Zip: ___________________________________________
Tel: Home ( ___ )____________________ Work: (___ )_________________
BUSINESS/Complaint
Against
COMPLAINT IS AGAINST: Please supply information requested below:
Name: _________________________________________________
Address: _______________________________________________
City/State/Zip:___________________________________________
Tel: (____)___________________Fax: (_____)____________________
Product/Service involved: __________________________________________________________________
Person dealt with: ___________________________Place of Transaction: ____________________________
Date purchased: ___________________ Was deposit paid? Yes / No Amount $ _______________________
Method of Payment: Cash_________ Loan__________ Credit Card __________Other ________________
Contract Signed: Yes / No Name of Witness(s): ______________________________________________
How did you complain? By Phone __________ By Letter _________ In Person _______________________
To Whom: ______________________________________________________________________________
When: __________________________________________________________________________________
IF AUTO COMPLAINT:
MAKE/MODEL: _____________________________________________________________________
VEHICLE I.D.# (on title registration): _________________ NEW / USED PURCHASE / LEASE
Odometer reading (at purchase): _______________________ Current mileage: ___________________
Purchase price: $ ___________________ Payments: $______________________________________
Total number of times vehicle has been repaired for the same problem or defect: ___________________
Total number of business days (Monday – Friday) vehicle has been in repair shop: _________________
Have you contacted another agency? ________________
Have you hired an attorney? ______________
If yes, please give the name of the
agency below.
If yes, please give the name of the
Attorney below.
Please sign the complaint form after briefly describing your consumer complaints. Try to explain your problem in
chronological order, using dates, if possible. When you return the completed form, please enclose clear copies
(keep original copies) of any bills, receipts, contracts, and advertisements, repair orders or any other relevant
documents.
State here what action, if any, you have taken to resolve this problem and what you would like as a remedy. (Please
print or type.)
May we send a copy of your complaint to the merchant? Yes ____________ No ______________
Signature: ____________________________________Date: ______________________________
CONFIDENTIALITY
Under most circumstances, the text of your complaint will be considered a public record, a copy of which is available to any member of the
public upon request. However, your name, address, phone number, and any other information that identifies you will
not be disclosed.
Furthermore, no part of your complaint will be disclosed in response to a request that asks specifically for a complaint submitted by you.