Price Gouging Complaint Form

Please fill in all information. Incomplete forms cannot be processed. required fields are noted with an asterisk*
Person Filing Complaint
Name (Use full, legal name):	*
Name of Purchaser (if different):
Address:
City:	*
State:	*
Zip Code:
Phone Number:	*
Alternate Phone Number:
E-mail Address:	*
Business/Person Complaining Against
If Person - Full Name:
Name of Business:
Address:
If Known, Name of Owner:
If Known, Person You Dealt With:
City:	*
State:	*
Zip Code:
County:	*
Telephone Number of Business:
Type of Business:	*
Goods/Services
Type of Business:	*
Item Purchased:	*
	**if other, please specify
Price Before Emergency:	*
Price After Emergency:	*
Do you have a receipt:	*
Was a purchase made?	*
Date of Purchase:	2008*
Time of Purchase:	*
Have you purchased this item at this location before?	*
Was the price previously advertised?	*
Was the price protested?	*
**If yes, what was said?
Would you be willing to testify?	*
Additional Comments:

For help or additional information contact the Florida Department of Agriculture and Consumer Services at 1-800-HELP-FLA (435-7352).