CONSUMER COMPLAINT

CONSUMER COMPLAINT

NOTICE: ASG/OAG does not legally represent you. (FA’AALIGA: E lē avea le Mālō po o le Ofisa o le Lōia Sili ma ou lōia.)
INSTRUCTIONS: The information that you provide will assist us in evaluating your complaint and give the company/business you are submitting your complaint against notice of the facts alleged. Please answer the questions in English as thoroughly as possible. If you are not comfortable answering in English, we will have someone from our office to assist you. Upon filling out this form, please attach copies of all agreements, contracts, letters/correspondence, and receipts relating to your complaint.

(FA’ATONUGA: O fa’amatalaga e te tu’uina mai e fesoasoani i le iloiloina o lau matāupu ma o
le a logoina fo’i le kamupanī/pisinisi o lo o fa’asaga i ai le matāupu e uiga i mea moni o lo o
tu’u’aia. Fa’amolemole tali fesili uma i le Gagana Fa’aperetania. Afai e mana’omia le
fesoasoani i le Gagana Samoa, o le a fa’atulagaina se tasi o le matou ofisa mo se fesoasoani. A mae’a ona fa’atumuina lenei pepa, fa’amolemole ia tu’uina mai ma kopi o ni maliliega tusitusia, konekarate, tusi/feutana’iga, ma lisiti e ono a’afia ai lou matāupu.)

Whether or not we agree to take your case, we will contact you. If we agree to take your case, we will investigate your complaint and contact the company/business. If we need additional information, we will contact you. If you resolve this matter, please contact us so that we can close our file.

(E logo atu e le matou ofisa pe talia pe lē talia lau matāupu. Afai e talia lau matāupu, e faia le matou su’esu’ga ma fa’afeso’ota’i le kamupanī/pisinisi. Afai e mana’omia nisi fa’amatalaga fa’aopoopo, matou te feso’ota’i atu lau susuga. Afai ua fō’ia lenei matāupu, fa’amolemole fa’afeso’ota’i mai matou ina ia mafai ai ona tapunia la matou faila.)

The Consumer Protection Bureau thanks you for the opportunity to serve you.
(E momoli atu le fa’afetai a le Ofisa o le Puipuiga o Tagata Fa’atau mo le avanoa e fesoasaoani atu ai i lenei matāupu.)
Contact Information

(Fa'amatalaga mo Feso'ota'iga)
First & Last Name (Suafa Atoa)*

First NameLast Name
Village & Mailing Address (Nu’u & Tuātusi/Pusa Meli)*

P.O. Box

VillageState / Province

Postal / Zip Code
Main Telephone (Telefoni):*

Area CodePhone Number
Cell Phone (Telefoni feavea’i):*

Area CodePhone Number
Complaint Information

(Fa'amatalaga mo le Matāupu))
Name of person or business that you are complaining against(Suafa o lē ona le Pisinisi / Igoa o le Pisinisi e fa’asaga i ai le Matāupu):*
Village & Mailing Address of Business (Nu’u & Tuātusi/Pusa Meli o le Pisinisi):*

P.O. Box

VillageState / Province

Postal / Zip Code
Main Telephone (Telefoni):*

Area CodePhone Number
Cell Phone (Telefoni feavea’i):*

Area CodePhone Number
Date of Transaction (Aso o le Fefa’ataua’iga):*

MonthDayYear
Date
I. General Description of Transaction (Fa’amatalaga o Fefa’ataua’iga):*
Name & Position of the person with whom you dealt (Suafa ma le Tulaga o lē sa e feagai ai):*

NamePosition
II. Please provide a detailed explanation of your complaint (Fa’amolemole tu’uina mai se fa’amatalaga atoatoa ma auili’ili e fa’amatalaina ai lau matāupu):*
III. Did you sign a contract (Na e sainia se konekarate po o se maliliega tusitusia)?*

Yes (Ioe)No (Leai)
IV. Have you contacted the company/business about your complaint (Ua e fa’afes’ota’iina le kamupanī/pisinisi e uiga i lau matāupu)?*

Yes (Ioe)No (Leai)
If so, what was the company/business’s response (Afai ioe, o le a le tali mai le kamupanī/pisinisi)?*
V. Itemize the approximate monetary value of the losses caused by the company/business (Lisi mai le tau fa’atatau o tupe sa fa’aaogaina ona o le kamupanī/pisinisi):*
VI. If you have consulted with a private attorney regarding this matter, please provide his/her name (Afai ua e fa’afeso’ota’iina se lōia tuma’oti e uiga i lau matāupu, fa’amolemole fa’ailoa mai lona suafa):*
Please upload attachments (receipts, contract/agreement, etc.) (Fa’amolemole ia tu’uina mai ma kopi o ni maliliega tusitusia, konekarate, tusi/feutana’iga, ma lisiti e ono a’afia ai lou matāupu):

Cancelof
Should be Empty:

CONSUMER COMPLAINT

Contact Information

Complaint Information