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Complainant Information
Last Name:
Middle Name:
First Name:
Date of Birth:
Last 4 of SSN:
DL/ID Number:
DL/ID State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Address:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
None
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Phone Number:
Email:
Subject of Complaint
Entity:
Business
Individual
Unknown
Full Name:
Date of Birth:
Address:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
None
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Phone Number:
Email:
Business Name:
Business Address:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
None
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Vehicle Information
Make:
Make
ACURA
ALFA ROMEO
AUDI
BERING
BMW
BUICK
CADILLAC
CATERPILLAR
CHEVROLET
CHEVROLET COMMERCIAL
CHEVROLET TRUCK
CHRYSLER
DAEWOO
DODGE
DODGE COMMERCIAL
EAGLE
FIAT
FORD
FORD COMMERCIAL
FORD TRUCK
FREIGHTLINER
GEO
GMC LIGHT DUTY
GMC MEDIUM DUTY
HINO
HONDA
HUMMER
HYUNDAI
INFINITI
INTERNATIONAL
ISUZU
ISUZU MED DUTY
JAGUAR
JEEP
KENWORTH
KIA
LAND ROVER
LEXUS
LINCOLN
MACK
MAZDA
MERCEDES-BENZ
MERCEDES-BENZ COMMERCIAL
MERCURY
MINI
MITSUBISHI
MITSUBISHI FUSO
NISSAN
NISSAN MEDIUM DUTY
OLDSMOBILE
PETERBILT
PLYMOUTH
PONTIAC
PORSCHE
SAAB
SATURN
SCION
SMART
STERLING TRUCK
SUBARU
SUZUKI
TOYOTA
TRAILERS
UD
VOLKSWAGEN
VOLVO
VOLVO COMMERCIAL
WESTERN STAR
Model:
Model
Year:
VIN:
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State:
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Detailed Report of Complaint
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I/we certify under penalty of perjury that the above information is true and correct to the best of my/our knowledge, information, and belief.Any person(s) using a fictitious name or address and/ or knowingly making any false statements on this application is in violation of DC Law and subject to a fine of not more than $1,000 or 180 days imprisonment or both. (DC Official Code § 22 - 2405)
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