Approved by OMB 3060-0874 (Est. average burden per response is 15 minutes).
Fields marked with * are required. The submit button will not be active until all required fields are completed.
Please provide the details of your issue. Do not enter personal information like name, address, phone or account number. There are places to enter that information below, if applicable.
Please select the issue that best describes your complaint.
Select a sub issue that best describes your situation.
If yes, describe in the description field what personal information has been accessed, obtained or used and how you discovered it.
If yes, attach or describe the notice, include the date you received the notice and what it contained.
Examples of the time format are: 1:00 pm or 2:45 p.m. or 8:51 P.M.
You can click in the field to use a calendar to select a date. If you enter the date it must be in the following format: January 1, 2015
Please enter the TV channel. For example 13 or 818
You must enter a specific name. Words like "all" or "every" will not be accepted.
If you selected other, please provide the name of the subscription service.
You can find the call sign while watching TV by using the info button on your remote or the channel guide.. Examples of a call sign are: "WZUF" or "WZUE-TV."
Please select the company that is the subject of your complaint. If the company is not listed, select "other" and provide the name of the company.
If you selected other from the list of Company Names, please provide the company name.
Please enter your account number, if applicable.
If you have a PO Box, please enter it in this field.
The format of the zip code can be: 20850 or 20850-1234
Please enter the phone number in the following format 555-555-5555
Please indicate whether you are filing this on behalf of someone else.