Consumer Complaint Form

To file a consumer complaint, please fill out the required information below and select the submit button once complete.  This allows us to receive your information by email. 

If you would instead like to submit a complaint by mail, you can print a pdf version of the complaint form here.  If you would like the complaint form in Spanish, please click here.  Once you fill out the form, please mail it to the address below.   

     Consumer Mediation Center
     Attorney General's Office
     2115 State Capitol, Lincoln, NE 68509

Complaint Reported By:

(Enter your name and address below)

Name
First
Last
Address
County
Day Phone
Home Phone
Your Age
 
 
 
 
 
 
 
Military (If Applicable)
 
 
Preferred Method of Correspondence
 
Have you contacted the business/person about your complaint?
 
 
Have you contacted an Attorney about your complaint?
 
 

Complaint Reported Against

(Enter their name and address below)

Name of the firm or person complained of
Address
Phone
Name of individual with whom you dealt

Complaint Information

Date of Purchase of Product
Method of Payment
Type of Product of Service
Cost of Product or Service
Actual Amount Paid
Describe the facts which have led to the complaint and be sure to include if possible, the exact dates of important events.
Please describe what resolution you are seeking for this complaint.
Related Documents

Please attach copies of any checks, receipts and/or supporting documents. Pleasae send clear, legible copies.
Files must be less than 16MB.
Allowed file types: gif jpg png txt rtf pdf doc docx xls xlsx zip.

Options
 
 
 

Disclaimer:
The information given above is true to the best of my knowledge and belief. I authorize the Nebraska Attorney General's Office to send this complaint form to the company or to the interested parties and to use the information given in any manner which is determined necessary. I understand that the Attorney General's Office is not my private attorney but represents the public in enforcing laws designed to protect consumers from misleading or unlawful business practices.

Agreement
 
Please enter the letters in the picture into the box.