International Marketing Supervision Network
Cross-Border Dispute Resolution System
 
Complaint Submitted By
Last name, first name:

Address:


City:
State/Province:
Postal Code:
Country:
Nature of the Complaint
Give the date of the transaction, terms, amount paid, and the basis for your complaint (for example, products were not as described, product was not delivered, etc.)

 

 

 
Attachments
Attach copies of any documents that relate to your claim.  Keep the originals.  Note which documents you are attaching.

 

 

 
Requested Resolution
How would you like this dispute to be resolved (your money returned, the item you ordered delivered, etc.)?

 

 

 
Company Against Which Complaint is Directed
Company Name:

Address:

City:
State/Province:
Postal Code:
Country:
Response of the Company
___ I agree to implement the resolution that the consumer requested.  [Describe the action that you will take to resolve the dispute.]

 

 

 
___ I agree to implement parts of the resolution that the consumer requested.  [State why you do not fully agree, and describe the action that you will take to resolve the dispute.]

 

 

 
___ I do not agree with the resolution that the consumer requested. [State why you disagree.]

 

 

 

 
 

Signature of Company Representative: _____________________________________

Date: ______________________________