Money Had and Received Complaint Intake Form
Please provide detailed information about your complaint regarding money had and received matters. Complete all relevant sections to help us process your case efficiently.
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Who is the complaint against? (Name or Organization)
*
Relationship to the respondent
*
Please Select
Individual
Business
Other
Amount of money involved (in USD)
*
How was the money paid or received?
*
Cash
Bank transfer
Check
Mobile payment app
Card (last 4 digits only)
Other
Date of payment or receipt
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If payment involved a card, enter last 4 digits only
Describe what happened
*
What resolution are you requesting?
*
Upload any supporting documents (optional)
Upload a File
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