|
Motor Carrier Division |
|
555 Wright Way |
|
Carson City, Nevada 89711 |
|
(775) 684-4711 |
|
www.dmvnv.com |
|
|
|
COMPLAINT |
VOLUNTARY STATEMENT |
Case No. _______________ |
File Date ______________ |
I wish to file a complaint against the business or individual named below. I understand that the Department of Motor Vehicles DOES NOT represent private citizens seeking return of monies or other personal remedies as a result of contractual disputes or civil actions.
Person Filing Complaint:
Name _______________________________________________________Day Time Phone ______________________
Address _____________________________________________________Home Phone _________________________
City _______________________________________________________________State ____________Zip __________
Business or Individual Complaint Filed Against: |
Business License No _____________________ |
|
(If applicable) |
Business Name ____________________________________________Phone __________________________________
Address__________________________________________________________________________________________
City _______________________________________________________________State ____________Zip __________
Representative’s Name _____________________________________________________________________________
Vehicle Involved: (If applicable)
VIN |____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|____|
Year _______________Make _______________________Model ____________________Color ___________________
Other complaint not involving a motor vehicle sale or repair.
Explain Complaint: (Please attach copies of any documents you have to support your complaint.)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
I, _______________________________________________ freely and voluntarily give this affidavit to the State of Nevada,
Department of Motor Vehicles. I further certify and affirm that all information is true and correct to the best of my knowledge and that I will testify to these facts if requested to do so in any action brought against the business or individual named above.
Signatures must be original. Photocopies are not acceptable.
___________________________________________________ |
________________________________ |
Signature of Complainant |
Date |
___________________________________________________ |
________________________________ |
Signature of Notary OR Authorized DMV Representative |
Date |