Illinois Collectors Association, Inc.
Peter Kralka, Exec Secretary
Please fax to (919) 787-4916
We must have a signed form in order to investigat a complaint.
Person completing form:
____________________________________________________
Name: Home Telephone #:
_________________________________________________________
Address: Work Telephone #:
______________________________________________________
City: State: Zip:
__________________________ _____ _________
To forward your complaint, we will need to give your name to the collection agency you are complaining
about.
Complaint filed against (Company Name): _____________________________
Business Name: ___________________________________________________
Address (number, street, & suite #): ___________________________________
City: State: Zip:
Name of person(s) complaint is filed against:
Telephone #:
Have you complained to the company? Yes_____ No_____
By: Telephone_____ Letter_____ In Person_____
The date you complained to the company:
Person contacted:
Result of contact (use extra sheets if necessary):
Describe the events of your complaint in the order they happened, as briefly as possible, giving specific
names, dates, times, etc., whenever possible. (Use extra sheets if necessary):
What do you want the person or company to do to satisfy your complaint?
READ THE FOLLOWING BEFORE SIGNING BELOW
Keep a copy of this form for yourself. Return this original form to the Illinois Collectors Association, Inc. The filing of this complaint form is in addition to any of your legal rights and remedies.
By filing this complaint I authorize the collection agency to disclose information concerning this account(s) to ICA authorized staff and counsel for use in the ICA Consumer Complaint program.
I hereby certify under penalty of perjury under the laws of the state of Illinois that to the best of my knowledge all of the above statements are correct.
=========================== ====================
Your signature Date
Complaint form may be obtained currently by call our office.