Form FDACS-10903 "Motor Vehicle Repair Consumer Complaint Form" - Florida

What Is Form FDACS-10903?

This is a legal form that was released by the Florida Department of Agriculture and Consumer Services - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2014;
  • The latest edition provided by the Florida Department of Agriculture and Consumer Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form FDACS-10903 by clicking the link below or browse more documents and templates provided by the Florida Department of Agriculture and Consumer Services.

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Download Form FDACS-10903 "Motor Vehicle Repair Consumer Complaint Form" - Florida

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Please return completed complaint
Florida Department of Agriculture and Consumer Services
form to:
Division of Consumer Services
FDACS Mediation & Enforcement
2005 Apalachee Parkway
Tallahassee, Florida 32399-6500
MOTOR VEHICLE REPAIR
www.FloridaConsumerHelp.com
CONSUMER COMPLAINT FORM
1-800-HELP-FLA (435-7352)
ADAM H. PUTNAM
(850) 410-3800
COMMISSIONER
s. 570.544(4), Florida Statutes
This information MUST be provided for the department to mediate your complaint, as we correspond via U.S. mail. Incomplete
forms CANNOT be processed. PLEASE WRITE LEGIBLY. Only one business per complaint form.
Person Making Complaint:
Complaint is Against:
Ms. / Mrs. / Mr.
Last Name, First Name, Middle Initial
Name of Business
Mailing Address
Mailing Address
City, State, Zip Code, Country
City, State, Zip Code
Home and Business Phone, including Area Code
Business Phone, including Area Code
Email Address
Business Email and/or Web Address
Please check if you would like to receive our Florida Consumer E-Newsletter. Our newsletter provides monthly consumer tips and
information and is distributed by email.
Because certain age groups enjoy specific protections under the law, please select the box next to your age group:
25 – 35
36 – 45
46 – 55
Under 25
Over 55
Have you retained an attorney?
Yes
No
No
Yes
Have you filed suit in court?
If yes, you should rely on the advice of your attorney.
Year, make and type of vehicle involved:
Amount Paid: $
Refund or Restitution Amount You Are Requesting: $
Date of Repair:
Specify repair:
(Example: Transmission/Engine/Brakes/Electrical/Collision/AC/Other)
Did you receive a copy of the written estimate before the work was performed?
Yes
No
Were the repairs the same ones you authorized?
Yes
No
Did you authorize any changes to the original estimate?
Yes
No
PLEASE ATTACH COPIES, DO NOT SEND ORIGINALS
All documents and attachments submitted with this complaint are subject to public inspection pursuant to Chapter 119, F.S.
Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his
official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in Section 775.082, 775.083, or
837.06, F.S.
FDACS-10903 Rev. 08/14
Page 1 of 2
Please return completed complaint
Florida Department of Agriculture and Consumer Services
form to:
Division of Consumer Services
FDACS Mediation & Enforcement
2005 Apalachee Parkway
Tallahassee, Florida 32399-6500
MOTOR VEHICLE REPAIR
www.FloridaConsumerHelp.com
CONSUMER COMPLAINT FORM
1-800-HELP-FLA (435-7352)
ADAM H. PUTNAM
(850) 410-3800
COMMISSIONER
s. 570.544(4), Florida Statutes
This information MUST be provided for the department to mediate your complaint, as we correspond via U.S. mail. Incomplete
forms CANNOT be processed. PLEASE WRITE LEGIBLY. Only one business per complaint form.
Person Making Complaint:
Complaint is Against:
Ms. / Mrs. / Mr.
Last Name, First Name, Middle Initial
Name of Business
Mailing Address
Mailing Address
City, State, Zip Code, Country
City, State, Zip Code
Home and Business Phone, including Area Code
Business Phone, including Area Code
Email Address
Business Email and/or Web Address
Please check if you would like to receive our Florida Consumer E-Newsletter. Our newsletter provides monthly consumer tips and
information and is distributed by email.
Because certain age groups enjoy specific protections under the law, please select the box next to your age group:
25 – 35
36 – 45
46 – 55
Under 25
Over 55
Have you retained an attorney?
Yes
No
No
Yes
Have you filed suit in court?
If yes, you should rely on the advice of your attorney.
Year, make and type of vehicle involved:
Amount Paid: $
Refund or Restitution Amount You Are Requesting: $
Date of Repair:
Specify repair:
(Example: Transmission/Engine/Brakes/Electrical/Collision/AC/Other)
Did you receive a copy of the written estimate before the work was performed?
Yes
No
Were the repairs the same ones you authorized?
Yes
No
Did you authorize any changes to the original estimate?
Yes
No
PLEASE ATTACH COPIES, DO NOT SEND ORIGINALS
All documents and attachments submitted with this complaint are subject to public inspection pursuant to Chapter 119, F.S.
Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his
official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in Section 775.082, 775.083, or
837.06, F.S.
FDACS-10903 Rev. 08/14
Page 1 of 2
Please explain your complaint. Attach additional sheets if necessary.
**What would satisfy your complaint?
**The department cannot require businesses to take a particular action such as repairing or replacing a product, or refunding money. The
department may act as a mediator to attempt dispute resolutions; however, on occasion, the only recourse is to seek legal remedy
through the court system.
My signature authorizes the Florida Department of Agriculture and Consumer Services to take any action deemed necessary
for purposes of mediation, investigation or enforcement. I understand that the department does not give legal advice, and
cannot take legal action for me. I am filing this complaint to notify the department of the activities of this business/
individual and to seek any assistance available. I ACKNOWLEDGE THAT I AM AWARE THAT THE PERSON/ BUSINESS
WHICH I AM COMPLAINING AGAINST WILL RECEIVE A COPY OF THIS COMPLAINT.
Signature:
Date:
I am filing this complaint for information purposes only and DO NOT want mediation assistance.
My personal information is exempt from public records disclosure because I am a sworn law enforcement officer,
judge, or other individual specifically exempted by s. 119.071(4), F.S.
FDACS-10903 Rev. 08/14
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