home repair fraud complaint form › sites › default › files › f… · 23. please briefly...

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OFFICE OF THE STATE’S ATTORNEY

KIMBERLY M. FOXX COOK COUNTY, ILLINOIS Special Prosecutions Bureau STATE’S ATTORNEY Consumer Fraud Unit

50 W. Washington Street, Suite 2750 Chicago, Illinois 60602 (312) 603-8600 [email protected]

HOME REPAIR FRAUD COMPLAINT FORM

Note: Download the Complaint Form on to your computer before answering any questions. After you have entered the answers in the data fields, resave the document so that the answers appear on the final version of the Complaint Form. You may then email or mail the form to the Cook County State’s Attorney’s Office.

1. Answer each question of the Complaint Form. Remember to sign and date the last page of the Form and to send any supporting documents. Do not send original documents. The State’s Attorney’s Office may request additional documents from you later – retain your original documents.

2. Make sure that the Complaint Form that you are returning to the State’s Attorney’s Office contains your

answers.

3. Return the completed Form to the following email address: [email protected]. You may also return the Form by mail to the following address: Cook County State's Attorney's Office, Consumer Fraud Unit, 50 West Washington - Suite 2750, Chicago, IL, 60602

I. CONTACT INFORMATION

Name: ________________________________________________________________________

Age: ___________

Home Address: _________________________________________________________________

Telephone Number (Home): ___________________

Telephone Number (Work): ___________________

Telephone Number (Cell): _____________________

E-Mail Address: ______________________________________

mailto:[email protected]

mailto:[email protected]

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II. COMPANY AND/OR PERSON

1. Please identify the name, address, and contact information (telephone number and email address) of the company who engaged in the alleged fraud.

2. Please identify the name, address, and contact information (telephone number and email address) for

each person who engaged in the alleged fraud.

III. DESCRIPTION OF YOUR HOME

3. Is your primary residence a detached, single family home? [ ] Yes [ ] No 4. Is your primary residence part of a multiunit building? [ ] Yes [ ] No

If you answered “Yes” to Question #4, please identify the total number of units in your multiunit building: ______________________________________

IV. PLACE OF SOLICITATION

5. Were you first solicited at your home by the company or person who engaged in the alleged fraud? [ ] Yes [ ] No

V. KNOWLEDGE OF THE BUSINESS AND/OR PERSON

6. How did you become aware of the company or person who engaged in the alleged fraud?

7. Did the same company or person work on any previous home repair project for you before the incident of the alleged fraud? [ ] Yes [ ] No

VI. CONTRACT FOR HOME REPAIRS

8. Did you enter into a contract for home repairs with the company or person who engaged in the alleged fraud? [ ] Yes [ ] No

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If you answered “Yes” to Question #8, please identify the date of the contract: ______________

If you answered “Yes” to Question #8, please identify the total purchase price: ______________

If you answered “Yes” to Question #8, what was the address of the location where you entered into the contract? _______________________________________________________________

9. Were the contracted-for home repairs to be performed on your primary residence?

[ ] Yes [ ] No

If you answered “No” to Question #9, please identify the type of property (vacation home, investment property, commercial property, etc.) where the contracted-for repairs were supposed to be performed. _______________________________________________________

10. Did the company or person tell you anything that convinced you to enter into the home repair contract?

[ ] Yes [ ] No

If you answered “Yes” to Question #10, please describe what the company or person told you that convinced you to enter into the home repair contract.

If you answered “Yes” to Question #10, please identify the name, address, and contact information (telephone number and email address) of the person who convinced you to enter into the home repair contract.

If you answered “Yes” to Question #10, please identify when (date) and how (in-person conversation, telephone conversation, text, email, letter, etc.) the person convinced you to enter into the home repair contract.

If you answered “Yes” to Question #10, please identify the name, address, and contact information (telephone number and email address) of any other person who was present when the company or person convinced you to enter into the home repair contract.

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VII. INSURANCE COVERAGE

11. Did the company or person tell you about being insured or possessing insurance coverage to operate a home repair business? [ ] Yes [ ] No

12. Did the company or person show you a certificate of insurance or any other proof of insurance? [ ] Yes [ ] No

13. Did the company or person provide you with a certificate of insurance or any other proof of insurance? [ ] Yes [ ] No

VIII. WRITTEN CONTRACT

14. Does a written contract for the home repair project exist? [ ] Yes [ ] No 15. Did the company or person provide you with a copy of the written contract? [ ] Yes [ ] No

If you answered “Yes” to Question #15, please identify the name, address, and contact information (telephone number and email address) of the person who furnished you with the written contract.

If you answered “Yes” to Question #15, please answer Question #16. If you answered “No” to Question #15, please skip Question #16 and proceed to Question #17.

16. Does the written contract contain a “Notice of Cancellation” in substantially the following form?

YOU, THE CONSUMER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE ATTACHED NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT.

[ ] Yes [ ] No

17. Did the company or person provide you with two (2) “Notice of Cancellation” forms? [ ] Yes [ ] No 18. Did any person tell you, at the time you entered into or signed the contract for home repairs, of any

right to cancel the contract within three (3) business days? [ ] Yes [ ] No

IX. CONSUMER RIGHTS BROCHURE

19. Did the company or person provide you with a consumer rights pamphlet or brochure? [ ] Yes [ ] No

X. PAYMENT OF MONIES

20. Did you pay any monies to the company or person who engaged in the alleged fraud? [ ] Yes [ ] No

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If you answered “Yes” to Question #20, please identify the method of each payment. ______________________________________________________________________________

If you answered “Yes” to Question #20, please identify the amount and date of each payment. ______________________________________________________________________________

If you answered “Yes” to Question #20, what was the address of the location where you made each payment? _________________________________________________________________

If you answered “Yes” to Question #20, please identify the name, address, and contact information (telephone number and email address) of the person who obtained each payment from you.

21. Do you possess a receipt or any other proof of your payment of monies? [ ] Yes [ ] No 22. Did the company or person tell you anything that convinced you to pay any monies? [ ] Yes [ ] No

If you answered “Yes” to Question #22, please describe what the company or person told you that convinced you to pay any monies. If you answered “Yes” to Question #22, please identify the name, address, and contact information (telephone number and email address) of the person who convinced you to pay any monies.

If you answered “Yes” to Question #22, please identify when (date) and how (in-person conversation, telephone conversation, text, email, letter, etc.) the person convinced you to pay any monies.

If you answered “Yes” to Question #22, please identify the name, address, and contact information (telephone number and email address) of any other person who was present when the company or person convinced you to pay any monies.

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XI. WORK AND/OR MATERIALS PROVIDED

23. Please briefly describe the nature of the contracted-for home repairs.

24. When was the project supposed to be started? ______________________________________________25. When was the project supposed to be finished? _____________________________________________26. Did the company or person perform any home repairs? [ ] Yes [ ] No27. Please briefly describe the home repairs that were performed, if any.

28. When was the last date that work, if any, was performed on the project? _________________________29. Did the company or person deliver any materials? [ ] Yes [ ] No30. Please briefly describe the materials that were delivered, if any.

31. To your knowledge, did the company or person place an order or otherwise purchase any materials forthe project? [ ] Yes [ ] No

32. Were any subcontractors or other third parties involved in the project? [ ] Yes [ ] NoIf you answered “Yes” to Question #32, please identify the name, address, and contact information (telephone number and email address) of any subcontractors or other third parties who were involved in the project.

33. What is your estimate of the percentage (0%-100%) of the total project that was performed? ________

XII. EXPLANATION

34. Did you seek an explanation from the company or person for the failure to start or finish the project?[ ] Yes [ ] No

35. Did the company or person provide you with any explanation for the failure to start or finish theproject? [ ] Yes [ ] No

If you answered “Yes” to Question #35, please provide a brief summary of the explanation(s) provided.

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If you answered “Yes” to Question #35, please identify the name of the person(s) who provided the explanation(s). ______________________________________________________________

If you answered “Yes” to Question #35, please identify when (date) and how (in-person conversation, telephone conversation, text, email, letter, etc.) the person(s) provided you with the explanation(s).

If you answered “Yes” to Question #35, please identify the name, address, and contact information (telephone number and email address) of any other person was present when the explanation(s) was provided to you.

XIII. PARTIAL OR FULL REFUND

36. Did you ever seek a refund from the company or person who engaged in the alleged fraud?[ ] Yes [ ] No

37. Did the company or person provide you with a full or partial refund? [ ] Yes [ ] NoIf you answered “Yes” to Question #37, please identify the date and amount of the refund. ______________________________________________________________________________ If you answered “Yes” to Question #37, please identify the name of the person who provided the refund. ________________________________________________________________________

XIV. FINANCIAL LOSS

38. Did you suffer any financial loss because of the alleged fraud? [ ] Yes [ ] NoIf you answered “Yes” to Question #38, please provide the amount and a description of your loss. __________________________________________________________________________

XV. COMPLAINT MADE TO THE POLICE OR ANOTHER GOVERNMENT AGENCY

39. Did you file a complaint with the police or any other government agency because of the alleged fraud?[ ] Yes [ ] No

If you answered “Yes” to Question #39, please provide the name, address, and telephone number of the police department or other government agency where you filed the complaint. Please also provide the number of any police report.

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XVI. PRIVATE ATTORNEY

40. Did you hire a private attorney? [ ] Yes [ ] No If you answered “Yes” to Question #40, please provide the name, address, and telephone number of the private attorney.

XVII. PRIVATE LAWSUIT

41. Did you or your attorney file a private lawsuit against the company or person who engaged in the alleged fraud? [ ] Yes [ ] No

If you answered “Yes” to Question #41, please provide the case name, case number, and location of the court for the private lawsuit.

42. Did you obtain any money judgment in any private lawsuit against the company or person who engaged

in the alleged fraud? [ ] Yes [ ] No

XVIII. OTHER VICTIMS

43. Are you aware of any other person who is claiming that he or she was defrauded by the same person or company? [ ] Yes [ ] No

If you answered “Yes” to Question #43, please identify the name, address, and contact information (telephone number and email address) of any other person who is claiming that he or she was defrauded by the same person or company.

XIX. BUSINESS FAILURE OR BANKRUPTCY FILING

44. Are you aware of any business failure or closure by the company or person who engaged in the alleged fraud? [ ] Yes [ ] No

45. Are you aware of any bankruptcy filing by the company or person who engaged in the alleged fraud? [ ] Yes [ ] No

XX. IDENTIFICATION OF OTHER WITNESSES

46. Please identify the name, address, and contact information (telephone number and email address) of

any other person who has personal knowledge of the alleged fraud.

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XXI. REQUEST FOR ACTION

47. What result are you seeking from the State’s Attorney’s Office?

48. How did you become aware of the Consumer Fraud Unit of the Cook County State’s Attorney’s Office?

XXII. ADDITIONAL INFORMATION

49. Finally, please use the space below or a separate piece of paper to provide any additional information,which you believe, is important for the State’s Attorney’s Office to consider as part of its review of thealleged home repair fraud.

PLEASE INCLUDE COPIES of any RELEVANT DOCUMENTS (advertisements, web pages, photographs, contracts, receipts, proof of payment, cancelled checks (front and back), credit card statements, correspondence, etc.).

DO NOT SEND ANY ORIGINAL DOCUMENTS!

I understand and agree that the State's Attorney's Office may send a copy of my complaint form and disclose my identity and the nature of my complaint to (i) other government agencies, (ii) the company or person that I am complaining about, and/or (iii) other third parties.

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I understand that the Cook County State's Attorney's Office is not acting as my private attorney and that the State's Attorney's Office represents the public in the enforcement of various civil and criminal laws against fraudulent business practices. If I have any questions concerning my legal rights or responsibilities, I understand that I should consult a private attorney.

I certify that the above information is true and accurate to the best of my knowledge.

Signature (by typing your name below in the Signature Field, you are signing this document)

_____________________________________________________________ Date: ___________________

Printed Name: ______________________________________

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