Consumer Complaint Form

Do you have a Medical Complaint?

If you are filing a medical complaint, CLICK HERE to print, sign and mail our HIPAA release form. If you are not sure if your complaint requires a HIPAA form, please feel free to contact our office by calling 605-773-4400.

Consumer Complaint Form

Please fill out the following form to submit a online complaint to Consumer Protection or you can download or print the PDF Consumer Complaint Form.

Please be sure to TAB through the form and then click 'Submit' button when you are ready to submit your form.

NOTE: In order for our office to process your complaint, we will need your

full name, address, and phone number included on the complaint form.

We look forward to assisting you.

Online Consumer Complaint Form

The Attorney General of the State of South Dakota and the Division of Consumer Protection have the authority to investigate deceptive or misleading business/trade practices and take legal action on behalf of the State of South Dakota. Neither the Attorney General nor his staff can act as a private attorney for you. This Office is prohibited by law from providing legal advice to private parties. To preserve any private legal rights you have, you may wish to contact a private attorney in addition to contacting our office.

1. Consumer Data

Your Name:
Address:
City:
County:	State: Zip:
Home Phone:		Work Phone:
Email Address:
Were you under 18 when the transaction ocurred? Yes No
If you have talked to someone in the consumer protection office, please list their name:

2. Person or Company complained about

Company:
Repressentative:
Address:
City:	State: Zip:
Phone:

4. Where the transaction took place (Check one)

	My home		Internet
	Telephone		Other
	Firm's place of business		There was no transaction
	Mail

5. Date of Transaction

(mm/dd/yyyy)

6. Did you sign a contract?

Yes No

7. Product or Service

8. Price

Total:
Amount Paid to date:

9. How was the transaction financed?

10. Actions taken to date (Check appropriate responces)

	I have contacted the firm about my complaint
	Person Contacted:
	Date:	Their Reaction:
	I have attempted to cancel
	I have requested the merchandise
	I have retained a private attorney. (If so, list attorney's name and address)

	I have filed a complaint with another agency. (If so, specify)

11. Summary of Complaint

Please describe briefly what you wish to report. Give specific facts in the order they happened with all dates, etc. that you can recall. Please send (through postal mail) copies of any papers involved, such as advertisements, receipts, contracts, canceled checks, bills, financing papers and other documents related to your complaint. These documents will be returned to you upon request.

12. Who referred you to this Office?

13. Would you be willing to testify in court, if necessary?

Yes No

The Division of Consumer Protection has my permission to send a copy of this complaint to the person or company complained about. I have read the complaint and hereby certify that the information reported is true and correct to the best of my knowledge, information and belief.

Check to agree to the above statement

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