"Pre-need Complaint Form" - Mississippi

This Mississippi-specific "Pre-need Complaint Form" is a document released by the Mississippi Secretary of State.

Download the fillable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Secretary of State
(601) 359-9055
Regulation and Enforcement Division
fax (601) 576-2546
P.O. Box 136
www.sos.ms.gov
Jackson, MS 39205-0136
PRE-NEED COMPLAINT FORM
DIRECTIONS: The information you provide on this form is valuable to the Division’s investigation of
your complaint. Please furnish specific and detailed information, answer all questions that are
applicable to your situation, and be clear and concise in your answers. Failure to provide complete
information may delay the processing of your complaint.
COMPLAINT INFORMATION
Full Name _____________________________
Date ______________________________
Address _______________________________
County ____________________________
City/State/Zip __________________________
Work Phone ________________________
Occupation ____________________________
Home Phone _______________________
FACTS AND CIRCUMSTANCES
1. Against what establishment are you filing this complaint (name, address, and telephone
number)?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
2. If applicable, against whom are you filing this complaint (full name of individual,
address, and telephone number)?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. When and where was the contract entered into?
________________________________________________________________________
________________________________________________________________________
Page 1 of 3
Secretary of State
(601) 359-9055
Regulation and Enforcement Division
fax (601) 576-2546
P.O. Box 136
www.sos.ms.gov
Jackson, MS 39205-0136
PRE-NEED COMPLAINT FORM
DIRECTIONS: The information you provide on this form is valuable to the Division’s investigation of
your complaint. Please furnish specific and detailed information, answer all questions that are
applicable to your situation, and be clear and concise in your answers. Failure to provide complete
information may delay the processing of your complaint.
COMPLAINT INFORMATION
Full Name _____________________________
Date ______________________________
Address _______________________________
County ____________________________
City/State/Zip __________________________
Work Phone ________________________
Occupation ____________________________
Home Phone _______________________
FACTS AND CIRCUMSTANCES
1. Against what establishment are you filing this complaint (name, address, and telephone
number)?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
2. If applicable, against whom are you filing this complaint (full name of individual,
address, and telephone number)?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. When and where was the contract entered into?
________________________________________________________________________
________________________________________________________________________
Page 1 of 3
4. Was the above establishment and/or agent(s) registered with the Secretary of State’s
Office? If yes, was the certificate shown for verification?
_________________________________________________________________________
_________________________________________________________________________
5. Was the contract funded by trust or insurance?
_________________________________________________________________________
_________________________________________________________________________
6. Was any money invested? If so, how much?
_________________________________________________________________________
_________________________________________________________________________
7. Did the establishment refund any money? If so, how much?
_________________________________________________________________________
_________________________________________________________________________
8. Did the contract contain a revocation clause?
_________________________________________________________________________
9. What made you decide to use the above establishment and/or agent?
_________________________________________________________________________
_________________________________________________________________________
10. Specifically, describe your complaint.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
11. Keeping in mind that the Division cannot recover money on your behalf, how would you
like your complaint to be resolved? Please be specific.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Page 2 of 3
12. Describe any contacts you have had with the establishment and/or agent concerning your
complaint. Please forward copies of any correspondence and other documents between you
and the establishment and/or agent.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
13. Have you contacted any other agency regarding your complaint? If so, please furnish the
name of the agency, when filed, and status if known.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
14. Have you contacted a private attorney about this matter? If so, please include the attorney’s
name, address, and telephone number.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
15. If you are aware of anyone else who has had a similar complaint, please provide names and
addresses.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
OTHER INFORMATION
Documentary evidence is especially important. Please forward copies, not originals, of the
front and back of your canceled checks, contract, insurance policy(ies), correspondence, and
any other written materials pertaining to your complaint. If you need more space, please feel
free to attach additional pages. Return your documents and completed complaint form to:
Regulation & Enforcement Division
Mississippi Secretary of State
Post Office Box 136
Jackso n, Mississippi 39205-0136
________________________
Signature
________________________
Date
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