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Albany, NY 12224 0341 2019-2023
For mailing.
3. Complete the entire form. Incomplete or unclear forms will be returned to you.
4. Please attach photocopies—no originals—of supporting documents.
CONSUMER
Name
Home phone
Business phone
Street Address
Email address
City/Town
County
State
Zip
COMPLAINT:
Name of seller or provider of services
Phone
Email address
Street Address
Website
City/Town
County
State
Date of transaction
Cost of product or service
Method of payment
Did you sign a contract?
Date...
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