Dispute - Consumer Affairs

Dispute Form

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Complete the e-dispute form BELOW OR Complete, download and print the pdf form ABOVE

NOTE: Supporting documentation may be submitted by email (consumer@pbc.gov), US Mail, or fax (561-712-6610)
(*) Represents a REQUIRED VALUE

Your Contact Information

*First Name:

*Last Name :

*Address:

*City:

State:

*Zip:

Home Phone:

Work Phone:

Ext:

Email:

Invalid email address.

Fax:

Dispute Against

*Business/Landlord Name:

*Address:

Mailing address if different:

*City:

State:

*Zip:

Contact:

Work Phone:

Ext:

Email:

Invalid email address.

Fax:

Website:

Invalid email address.

Dispute Transaction

*Date of transaction:

Have you contacted the business or landlord about this dispute? {{item.disp}}

Did you sign a contract, lease, or document? {{item.disp}}

PLEASE FURNISH A COPY OF ALL DOCUMENTS,CONTRACTS,LETTERS, ETC.

List any other agencies/organizations you have contacted for assistance. What was the outcome?

* What resolution would you consider to be mutually fair?

Dollar amount in dispute (if applicable): $

Dispute Information

* Please give a complete summary of your dispute:

To provide the best possible service for consumers in Palm Beach County, please select:

Your age category: {{item.category}}

Do you have access to the internet? {{item.disp}}

Are you a full time resident? {{item.value}}