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Consumer Complaint Form Template

This document is an initial complaint form containing information about a complainant, respondent, and consumer transaction or discovery of facts. It includes the complainant's name, address, and other details. It also lists the name and address of the establishment and owner/representative being complained about. The form documents the date of the consumer transaction or discovery, a brief narration of facts, any documents submitted, and the relief demanded. It requires signatures of the complainant and authorized signatory to process the personal data collected according to privacy laws.

Uploaded by

Rodolfo Lastimoso Diaz Jr.
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© © All Rights Reserved
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1K views1 page

Consumer Complaint Form Template

This document is an initial complaint form containing information about a complainant, respondent, and consumer transaction or discovery of facts. It includes the complainant's name, address, and other details. It also lists the name and address of the establishment and owner/representative being complained about. The form documents the date of the consumer transaction or discovery, a brief narration of facts, any documents submitted, and the relief demanded. It requires signatures of the complainant and authorized signatory to process the personal data collected according to privacy laws.

Uploaded by

Rodolfo Lastimoso Diaz Jr.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Doc.

Control No __________

INITIAL COMPLAINT FORM

COMPLAINANT
Name:
(Title/ Prefix) (First Name) (Middle Name) (Last Name) (Suffix)
Address
:
(House/Building No./Building Name) (Street Name) (Barangay)

(City/Municipality) (Province) (Region) (Zip Code)


E-mail: Tel/Cel #:
Social Classification:  Senior Citizen  Youth (15-30)  Out of School Youth Sex:  Male  Female
 Abled  Differently Abled  Indigenous Person
RESPONDENT
Name of Establishment:
Name of Owner/
Representative: (Title/ Prefix) (First Name) (Middle Name) (Last Name) (Suffix)
Address of Establishment:
(House/Building No./Building Name) (Street Name) (Barangay)

(City/Municipality) (Province) (Region) (Zip Code)


E-mail: Tel/Cel #:

Date of Consumer Transaction/Discovery: ________________________________________________________


Brief Narration of Facts:

____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________

Documents Submitted: ________________________________________________________________________


________________________________________________________________________
Relief Demanded:  Repair  Replace  Refund
 Others ___________________________________________________________

IN WITNESS WHEREOF, I have hereunto set my/our hand/s this day of 20 , in


, Philippines.

______________________
Complainant

All personal data collected herein shall be processed according to the principles and provisions of the Data
Privacy Act of 2012 (DPA), its Implementing Rules and Regulations (IRR), and National Privacy Commission
(NPC) issuances.

______________________________________________________
(Signature over Printed Name of Authorized Signatory)

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