DTC Complaint Form Generic

Account Holder Information.

Please complete all required fields marked with a *

Title*

First Name*

Last Name*

Business Account (Y/N)*

Business (if applicable)

Street*

City*

State*

Zip Code*

Contact Phone

e.g. (xxx) xxx-xxxx

Mobile Phone

e.g. (xxx) xxx-xxxx

Email*

Best Way to Reach You to Discuss Your Complaint*

Advocate Information

You are required to complete this section if your name does not appear on the bill or if you are not an authorized user of the account.

Title

First Name

Last Name

Street

City

State

Zip Code

Contact Phone

e.g. (xxx) xxx-xxxx

Mobile Phone

e.g. (xxx) xxx-xxxx

By selecting "Yes", I confirm that I have permission from the account holder to submit this complaint on their behalf.

Complaint Information

Service Provider*

Service Type*

Service Issue*

Your Account Number*

Please provide a detailed description of your problem*

2500 characters left

By selecting "Yes", I authorize the DTC to contact my service provider and obtain related account information in an attempt to resolve my complaint.*

The text of your complaint will be considered public record and be available to any member of the public upon request. Generally, we do not disclose your name, address, phone number or any other information that identifies you and will not disclose this form.

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