Weights and Measures
Consumer Complaint Form

Complainant's Name:

Street Address:

City, State, Zip:

May we contact you by phone? Yes No

Home Phone Number (with area code):

Work Phone Number (with area code):

Date of Incident: / / (MM/DD/YY)

Time of Incident: (HH:MM) A.M. P.M.

Business Name:

Street Address:

City, State, Zip:

Nature of Complaint:

• Awareness Days
• Firewood
• Gas Pump
• Scales
• Scanner
• Short Weight
• Misc.

Please explain your complaint: