CPFR-2 Rev 8/06
STATE OF CONNECTICUT
DEPARTMENT OF CONSUMER PROTECTION
165 Capitol Avenue Hartford CT 06106
Fax No. (860) 713-7239
1. Complete this form. Type or print CLEARLY.
2. Return form to Agency at address shown above.
For Official Use Only
HOME PHONE (Include Area Code)
BUSINESS PHONE (Include Area Code)
ARE YOU 65 OR OLDER?
PARTY/COMPANY COMPLAINED AGAINST
PERSON DEALT WITH / TELEPHONE NUMBER (Include Area Code)
INFORMATION: WAS A CONTRACT INVOLVED
IF “YES”, ENTER DATE
TYPE OF CONTRACT:
PRODUCT OR SERVICE INVOLVED
HOW PAID (CIRCLE ONE)
INSTALLMENT CONTRACT LAW-AWAY
WAS THE PRODUCT OR SERVICE ADVERTISED
DATE & PLACE OF AD (PLEASE ATTACH COPY IF POSSIBLE)
HAVE YOU CONTACTED THE COMPANY REGARDING
IF “YES” ENTER DATE
HAVE YOU HIRED AN ATTORNEY
IF “YES”, NAME
IS COURT ACTION PENDING?
IF “YES”, IN WHAT COURT?
NOTE: For Home Improvement and New Home Contractor complaints, we request a copy of your contract and copies of the back and
front of the cancelled checks. Otherwise, DO NOT send any other paperwork or documentation with your complaint at this time. If
further documentation is needed you will be notified. We will not be able to return or forward any material sent to this department.
Please provide a detailed statement regarding the facts of your complaint below. We encourage consumers to try and resolve their
issues with the company involved. More information can be obtained from our website: www.ct.gov/dcp. You may also find
information on the Small Claims Court and Superior Court process at www.jud.state.ct.us.