Consumer Assistance Request Form

Consumer Assistance Request Form

The Consumer Assistance Request Form is used if you need help with a consumer problem such as unsatisfactory service, bill disputes, or other concerns and would like the Attorney General’s Office to contact the organization on your behalf.

If this is a complaint against a healthcare provider, please fill out our Authorization for Release of Medical Information Form first and submit it along with your complaint using the "attach files" button below.

If this is a complaint against a credit card company, bank, credit union or financial institution, please fill out our Financial Authorization Form and submit it along with your complaint using the "attach files" button below.
* indicates required field
Complaint Type *
Language:
Your Information
Your Name *

Prefix First Name Last Name Suffix
Your Suffix
example: Jr., Sr., etc.
Your Company/Organization (if applicable)
Your Street Address *
Your Street Address Line 2
Your City *
Your State *
Your Zip Code *
Your Primary Phone *
Your Alternate Phone
Your Email *

Confirmation Email example@example.com
Company Complained About
Name Company You Are Complaining About *
Contact Person
Contact Person Title
Company Street Address
Company Street Address Line 2
Company City
Company State
Company Zip Code
Phone Number
Company Email
example@example.com
Other Information
Have you contacted another agency? *

Yes No
Agency You Contacted

MN Public Utilities Commission MN Dept of Commerce MN Dept of Revenue MN Dept of Human Rights Consumer Financial Protection Bureau (CFPB) Dept of Justice (DOJ) Federal Communications Commission (FCC) Federal Bureau of Investigation (FBI) Internal Revenue Service (IRS) Federal Trade Commission (FTC) US Postal Inspection Service (USPIS)
Result of Contacting Agency
Have you filed a lawsuit? *

Yes No
Court File No.
What was the result?
Product, Service, or Payment Involved
Product/Service Involved
Date of Purchase

Month Day Year
Amount of Purchase ($ USD)
Customer ID or Account Number
Explanation & Resolution
Explanation of the Problem *
What do you want the company to do? *
Attachments

Attach Files
Max total size limitation: 10 MB. Accepted file types: pdf, doc, docx, xls, xlsx, csv, mp3 Cancel of
By choosing Accept below, I consent to and acknowledge that the information I am providing may be used and/or disseminated by the Minnesota Attorney General’s Office: (a) to resolve the issue about which I am contacting the Office, including by contacting any person or entity complained against; (b) to communicate with me; (c) to other law enforcement agencies and/or consumer-assistance agencies; and (d) to otherwise assist in enforcing the law. Except as otherwise authorized by this consent, I understand that the information I am providing will be treated as “private data on individuals” under the Minnesota Government Data Practices Act, Minn. Stat. ch. 13, and shall not be used or disseminated except as authorized under the Act or other applicable state or federal law. I understand that I am not legally required to provide the information I have submitted in this form, but that my failure to do so may make it more difficult to resolve my concern. *

Accept
If you want a printed copy of your form, please click "Print Form" before submitting.
Should be Empty:

Consumer Assistance Request Form

Your Information

Company Complained About

Other Information

Product, Service, or Payment Involved

Explanation & Resolution