Bureau of Internet & Technology Online Complaint Form

First Name*
Last Name*
Street Address*
City/Town*
State*	- None - ARMED FORCES AMERICAS ARMED FORCES EUR/CAN/ME/AFR ARMED FORCES PACIFIC ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING AMERICAN SAMOA FEDERATED STATES OF MICRONESIA GUAM MARSHALL ISLANDS NORTHERN MARIANA ISLANDS PALAU PUERTO RICO U.S. MINOR OUTLYING ISLANDS VIRGIN ISLANDS OF THE U.S.
Zip*
Home Phone*	(Note: Format should be 123-456-7890)
Business Phone	(Note: Format should be 123-456-7890)
Email Address*

Name of Seller or Provider of Services*
Street Address*	-select- Address Known Address Unknown
Street Address*
City/Town*
State*	- None - ARMED FORCES AMERICAS ARMED FORCES EUR/CAN/ME/AFR ARMED FORCES PACIFIC ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING AMERICAN SAMOA FEDERATED STATES OF MICRONESIA GUAM MARSHALL ISLANDS NORTHERN MARIANA ISLANDS PALAU PUERTO RICO U.S. MINOR OUTLYING ISLANDS VIRGIN ISLANDS OF THE U.S.
Zip*
Phone	(Note: Format should be 123-456-7890)
Email Address
Website*
Date of Transaction
Cost of Product or Service	(Note: Enter a number with no special characters, such as '$')
Method of Payment

Did you sign a contract?*	-select- Yes No
Date Signed
Where Signed
Was the product or service advertised?*	-select- Yes No
Date Advertised
Where/How Advertised
Method of complaint to company or individual*	-select- Email Telephone In Person None
Complaint Date
Person Contacted
Job Title
Nature of Response
Date of Response
Has matter been submitted to another agency?*	-select- Yes No
Name
Address
Phone
Email Address
Is court action or other legal proceeding pending?*	-select- Yes No
Please Describe
Briefly describe your complaint*
What form of relief are you seeking? (e.g. refund, credit, exchange, repair, etc.)

Please upload any supporting documentation, e.g., screenshots, photos, email or other correspondence, terms of use, contracts, warranties, bills, statements, canceled checks, etc.

>  You may upload up to 4 files with a total file size limit of 20 megabytes.

>  Accepted document types: TXT, DOC, DOCX, XLS, XLSX, PDF.

>  Accepted image types: BMP, GIF, JPG, PNG, TIF, TIFF.

	The Attorney General is not my private attorney, but represents the public in enforcing laws designed to protect the public from misleading or unlawful business practices. My filing this complaint does not mean that the Attorney General has initiated a lawsuit or proceeding on my behalf or that it will do so.
	The Attorney General cannot give me legal advice or represent me in court. If I have any questions concerning my legal rights or responsibilities, I should contact a private attorney.
	In order to resolve my complaint, the Attorney General may send a copy of my complaint and any documents I provide to the person or business about whom I am complaining and I authorize that person or business to release information concerning my complaint to the Attorney General.
	The Attorney General works with other state, local and federal government agencies to investigate complaints and coordinate law enforcement and may also share my complaint with them. In addition, the Attorney General may use information from my complaint in legal proceedings to establish violations of law.
	Any false statements made in this complaint are punishable as a Class A Misdemeanor under Section 175.30 and/or Section 210.45 of the Penal Law.

This is for testing whether you are a human visitor and to prevent automated spam submissions.