Section 1 - Your Contact Information First Name * Last Name *



Street Address *



City * State Zip



---- AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY County * Florida Residents Phone Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia DeSoto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Miami-Dade Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam Saint Johns Saint Lucie Santa Rosa Sarasota Seminole Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington



E-mail Address *



Confirm E-mail Address *



Section 2 - Who is your complaint or inquiry about? Subject/Category *



Name/Firm/Company *

Street Address



City State Zip



AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY County Phone Alachua Baker Bay Bradford Brevard Broward Calhoun Charlotte Citrus Clay Collier Columbia Dade DeSoto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam Saint Johns Saint Lucie Santa Rosa Sarasota Seminole Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington



Website



Date of Transaction Amount Paid



Payment Method Cash Cashier's Check Personal Check or Bank Debit Credit Card Wire Transfer (such as Western Union, Money Gram, Bank Wire) Prepaid Debit (such as Green Dot MoneyPak or others)



Questions/Comments





Are you 60 or older? (Penalties can be enhanced for victimizing senior citizens) Yes No



Military status? Active Veteran N/A



I understand that your office does not give legal advice. I also understand that your office cannot take legal action for me individually.



All information submitted with this complaint is subject to public inspection pursuant to Chapter 119, Florida Statutes. Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082, s. 775.083, or s. 837.06, Florida Statutes. Note:

I am filing this complaint to notify your office of the activities of this business/individual and to seek any assistance you may be able to render.





TO REPORT LIFE THREATENING EMERGENCIES, SAFETY CONCERNS, OR IF POLICE ASSISTANCE IS IMMEDIATELY NEEDED, DIAL 9-1-1 or contact local law enforcement authorities who receive and respond to calls for service 24 hours a day.

PLEASE NOTE: The Office of Citizen Services' operators do NOT monitor emails on weekends, holidays, or after weekday business hours (M-F 8AM-5PM). Please do not rely on electronic communications to report urgent emergencies or safety concerns. Dial 911 instead.

In addition, please report known or suspected abuse/neglect/exploitation of a child or vulnerable adult to the state's Abuse Hotline at 1-800-962-2873 or online at https://reportabuse.dcf.state.fl.us or call 911.

Otherwise, the Office of Citizen Services will address online complaints and messages as quickly as possible.





