Please choose a request type below - Default Ticket Form TV Internet Radio Phone Emergency Accessibility Request for Dispute Assistance Tell Your Story

Your email address

Subject

Description Please describe your problem and what could be done to solve your problem. Try to describe your problem in no more than 3-5 sentences. Do not enter personal information like name, address, phone or account number. There are places to enter that information below, if applicable.

Phone Issues Scroll through the list to select the issue that best describes your complaint.

Unwanted Calls Sub Issue

Phone Availability Sub Issue Select a sub issue that best describes your situation.

Phone Billing Sub Issue Select a sub issue that best describes your situation.

Phone Equipment Sub Issue Select a sub issue that best describes your situation.

Phone Interference Sub Issue Select a sub issue that best describes your situation.

Has your personal information been accessed, obtained or used by an unauthorized person? If yes, describe in the description field what personal information has been accessed, obtained or used and how you discovered it.

Did you receive written notice from your provider about the data breach? If yes, attach or describe the notice, include the date you received the notice and what it contained.

Did the call/message that you are reporting advertise any type of property, goods, or services?

Type of Property, Goods, or Services Please indicate the type of property, goods, or services that were advertised.

Have you or anyone else in your household done any business with the caller/company within the past 18 months immediately before you received the call/message?

Have you or anyone else in your household made any inquiry or application to the caller/company within the 3 months immediately before you received the call/message?

Do you or anyone in your household have a personal relationship with the individual that made the call?

Your Phone Method Please select how you receive your phone service.

Telephone Number Subject of Complaint Please enter the phone number in the following format 555-555-5555

Your Phone Type/Location

Telephone Number Where the Unwanted Call/Message was Received Please enter the phone number in the following format 555-555-5555

Please indicate if the telephone number subject to this complaint is registered on the Do Not Call List

Rural Call - Telephone Number Called Please enter the phone number in the following format 555-555-5555

Rural Call - Telephone Number Calling From Please enter the phone number in the following format 555-555-5555

Rural Call - Caller's Long Distance Provider

Rural Call - Service Provider Are you a service provider filing on behalf of a customer?

Date of Your Issue/Problem You can click in the field to use a calendar to select a date. If you enter the date it must be in the following format: January 1, 2015

Time of Your Issue/Problem Examples of the time format are: 1:00 pm or 2:45 p.m. or 8:51 P.M.

Fax Advertiser Transmission Date Please provide the transmission date in the header line of the fax. You can click in the field to use a calendar to select a date. If you enter the date it must be in the following format: January 1, 2015

Type of Property, Goods, or Services for Fax Advertisement Please indicate the type of property, goods, or services that were advertised.

Permission to Fax Have you or anyone else in your household or business given the fax advertiser permission to fax?

Business Relationship with Fax Advertiser Have you or anyone else in your household or business done any business (including an inquiry or application) with the fax advertiser?

Fax Attached A copy of the fax must be attached to your submission. Please check the box to confirm that you are attaching a copy of the fax.

Type of Call or Message Please indicate the type of call or message received.

Have you or anyone else in your household or business given the caller/company permission to call?

Did you give permission to the caller/business to call you in writing?

Date you provided permission to the caller/company to call You can click in the field to use a calendar to select a date. If you enter the date it must be in the following format: January 1, 2015

Did you receive Caller ID Information?

Caller ID Number Please enter the phone number in the following format 555-555-5555. If the phone number you are reporting is an international phone number that does not match this format, please provide it in the Additional Information field below.

Caller ID name Please enter the name received on the Caller ID.

Was the caller's business name provided during the call/message? Only provide information received during the call/message itself, and not information received through Caller ID.

Was the business name provided at the beginning of the call/message?

Please provide the name of the advertiser provided during the call

Provide the advertiser's phone number given during the call. Please enter the phone number in the following format 555-555-5555. If the phone number you are reporting is an international phone number that does not match this format, please provide it in the Additional Information field below.

Company Name Please select the company that is the subject of your complaint. If the company is not listed, select "other" and provide the name of the company.

Company Name (Other) If you selected other from the list of Company Names, please provide the company name here. Also, attach a recent bill/statement by selecting Attachments at the bottom of the form.

Additional Company Name Please select the other company that is the subject of your complaint in instances including number portability and rural call completion. If the company name is not listed in the drop down, select "other" from the list and provide the name of the other company.

Additional Company Name (Other) If you selected other from the list of Company Names, please provide the company name.

Relationship to Company

Have you contacted this company about your issue?

Account Number Please enter your account number, if applicable.

Wireline Phone Please check the box to confirm that the phone is a wireline phone. Only wireline phones are subject to the FCC's slamming rules. Wireless phones are not.

Phone Bill for Slamming A copy of your phone bill must be attached to your submission. Please check the box to confirm that you are attaching a copy of your phone bill.

State for Slamming Issue If your state is not listed in the state field, you need to file a complaint with your state Public Utilities Commission. Please go to http://www.fcc.gov/encyclopedia/slamming for information on how to file your complaint with your state Public Utilities Commission.

Residential or Business Telephone Please indicate if your phone number is a residential or business telephone.

Local Telephone Provider Please provide the name of your authorized local telephone provider

Long Distance Telephone Provider Please provide the name of your authorized long distance telephone service provider that the service was changed from.

Back with Authorized Telephone Provider Please indicate whether you are back with your authorized telephone company

Disputed Charges Paid Please indicate if any of the disputed charges were paid.

Disputed Charges Adjusted/Refunded Please indicate if the disputed charges were adjusted or refunded.

Amount of Charges Please enter two decimal places

How Much Adjusted/Refund Please enter amount to two decimals. For example, 10.25.

Additional Information Please provide any more information you would like to share about this call or your interactions with this company.

Your First Name

Your Last Name

Address 1 If you have a PO Box, please enter it in this field.

Address 2

City

State

Zip Code The format of the zip code can be: 20850 or 20850-1234

Phone (where you can be contacted) Please enter the phone number in the following format 555-555-5555

Filing on Behalf of Someone Please indicate whether you are filing this on behalf of someone else.

Your Relationship (on behalf of)

First Name (on behalf of)

Last Name (on behalf of)

Company Name (on behalf of)

Address (on behalf of)

City (on behalf of)

State (on behalf of)

Zip Code (on behalf of) The format of the zip code can be: 20850 or 20850-1234

Attest I declare under penalty of perjury that (1) I am over 18 years old, (2) I am authorized to make decisions regarding the telephone number listed below, and (3) the information I have provided today on this Federal Communications Commission electronic form is, to the best of my knowledge, true and correct.