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CONSUMER COMPLAINT FORM

Please try to provide us with as much information as possible. The more we know, the better we can look into your complaint. Fields that are highlighted on this form are required. Please try to complete the other fields if possible. If you are filing a complaint on a gas pump or store "counter" scale, such as what you see in the meat department or by the cash registers, please give the pump number or scale location. For gas pumps we also need to know what grade of gas was used. Examples: Pump Number 4, Regular; Deli Scale OR Register Number 7 Please provide us with the details of your complaint. An example would be: "I turned on the pump and saw the handle was leaking." or "The automatic shut off didn't work and gas splashed out of the filler pipe."

We thank you for your time and effort.
Butler County Auditor- Weights & Measures - Working for Equity in the Marketplace

 

 Complainant: Personal Information
Name:
*required
First Last
Home Address:
City:
State:
ZIP Code:
Day Phone:
* required Example: 513-422-5555
Evening Phone:
Example: 513-422-5555

 Store or Business Information
Store/Business Name:
*required
Address:
City:
State:
ZIP Code:
 
If the address is unknown please describe location.
Example: "Corner of Niles and Dixie Highway."
Business Type:

Complaint Details
Involved Parties:
Date Occurred:
Time:
Device Involved:
Location of Device:
Details of the incident:
* required

 Information of person you spoke to about issue:
Name:
First Last
Person's title:
Phone:
Example: 513-422-5555
May we give your name to the store?




 Witness information (If any):
Name:
First Last
Address (if known):
City:
State:
ZIP Code:
Phone:
Example: 513-422-5555

Additional Information/Comments:


Butler County Administration Building: 130 High Street, 3rd & 4th floors, Hamilton, OH 45011 Phone: 513-887-3154 FAX: 513-887-3149
© 2017 Butler County Auditor