FMCSA - Commercial/Consumer Complaint Form

U.S. Department Of Transportation
Federal Motor Carrier Safety Administration

COMMERCIAL/CONSUMER COMPLAINT FORM

400 Seventh Street SW, MC-PA Washington, DC 20590

Date of Report:		Please Check the Appropriate Line
		Type: Shipper Carrier Freight Forwarder Broker Other
Name of Complainant:
Street Address:
City, State/Province, Zip Code:
Telephone No., Fax No.,
E-Mail:
USDOT/MC Number:


		Please Check the Appropriate Line Type: Motor Carrier - Property Motor Carrier - Household Goods Freight Forwarder ___ Broker Shipper/Receiver (Lumping) ___ Mexican Carrier ___ Owner/Operator Motor Carrier - Passenger
Name of Respondent:
Street Address:
City, State/Providence, Zip Code:
Telephone No., Fax No., E-Mail:

USDOT/MC Number:



Complaint Reason
Please Check the Appropriate Line
Household Goods Estimate/Final Charges Pick-up/Delivery ___Hostage	Loss/Damage ___Claim Settlement Property Brokers ___Unauthorized Operations Owner-Operator Leasing		Personal Automobiles Lumper Loading/Unloading Weight Other
Remarks: (Add attachments if additional space is needed) Please provide copies of all paperwork

Handled by ______________________ Date Closed________________ Complaint #___________