Weights and Measures Consumer Complaint Form

Contact Information

First Name

Last Name

Phone Number

Phone number

Email address

Email address

Address

Address 2

City/Town

State

- Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

ZIP

Would you like to remain confidential when we contact the business?

Yes

No

Complaint Information

Business Name

Name of business compaint is against

Business Address

Address

City/Town

State

- Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

ZIP

Type of Complaint

Type of Complaint

- Select -Motor FuelScaleShort Weight/MeasurePrice OverchargeOther…

Enter other…

If complaint is in releation to fuel:

Type of Fuel

- Select -DieselGasoline

Octane

- Select -87899193E85Non-Ethanol

When did this take place?

When did this take place?: Date

When did this take place?: Time

Please describe your complaint

Upload photos if necessary

Photos of complaint

Maximum 6 files.
8 MB limit.
Allowed types: gif, jpg, jpeg, png, svg.

I understand under PL 210.45, that making a false written statement is a Class A Misdemeanor, punishable by up to a year in jail.

I understand under PL 210.45, that making a false written statement is a Class A Misdemeanor, punishable by up to a year in jail.

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