Imperial County
District Attorney's Office
George Marquez, District Attorney
Who We Are
Contact Us
Mission Statement
Programs
Domestic Violence
Victim Witness Program
Elder Abuse
Bad Check Restitution Program
Career Day
Drug Store Program
Report fraud
Auto Insurance Fraud
Public Assistance Fraud
Real Estate Fraud
Resources
Helping Victims
Family Justice Center
Frequently Asked Questions
Testifying in Court
Community Outreach Form
Marsy's Law
Who We Are
Contact Us
Mission Statement
Programs
Domestic Violence
Victim Witness Program
Elder Abuse
Bad Check Restitution Program
Career Day
Drug Store Program
Report fraud
Auto Insurance Fraud
Public Assistance Fraud
Real Estate Fraud
Resources
Helping Victims
Family Justice Center
Frequently Asked Questions
Testifying in Court
Community Outreach Form
Marsy's Law
Automobile Insurance Fraud Referral
Guidelines
I. COMPLAINANT
(Person Filing Complaint)
First Name
*
Middle Name
Last Name
*
Date of birth
*
Ocupation
*
Driver's License or ID Number
*
Street Address
*
Apartment, suite, etc
City
*
State/Province
*
ZIP / Postal Code
*
Email Address
*
Email Address
*
Fax Number
Phone Number 1
*
Phone Number 2
II. BUSINESS/SUSPECT COMPLAINT IS AGAINST
Name of business
*
Street Address or PO Box
Apartment, suite, etc
City
State/Province
ZIP / Postal Code
Phone Number
Individual Name
Race
Male/Female
Height
Weight
Street Address or PO Box
Apartment, suite, etc
City
State/Province
ZIP / Postal Code
Phone Number
III. TRANSACTION INFORMATION
Date of ocurrence
*
VIN (Vehicle Identification Number)
*
Make, model, color, license plate
*
Nature of complaint
*
Date of purchase
*
Purchase price/Amount of loss
Method of payment
Name, address and phone number of witnesses, if any
Name, address and phone number of victims, if known
How did you hear about the business
Did you contact the business about your complaint?
*
Yes
No
Name of the person contacted
*
Result of contact
*
List other agencies you have contacted
Have you contacteda private attorney?
*
Yes
No
Name of the attorney
*
Any civil lawsuits pending, including small claims?
*
Yes
No
Any judgements?
*
Yes
No
May we provide a copy of your complaint and information to other government or consumer agencies? ?
*
Yes
No
IV. Complaint
Decription
V. Attachments
To help explain the details of your complaint, YOU MUST SUPPLY PHOTOCOPIES OF THOSE DOCUMENTS RELATED TO YOUR COMPLAINT. Include insurance cards, vehicle registration, pictures, etc.
Attachment descriptions
Upload files
Drag and Drop (or)
Choose Files
ID, Insurance, any important document
VI. Declaration
Date and sign below – anonymous referrals are not accepted
NOTE: California Penal Code Section 148.5(a) states:
I declare under penalty of perjury under the laws of the State of California that the foregoing statements and photocopies of attached documents are true and correct.
Date
*
Signature
Your name will be used as E-signature
Submit Form