Home Improvement or Auto Fraud Form Name First Middle Last PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country OccupationEmployment StatusEmployedRetiredName of contractor or dealership you are complaining about:Summary of your issue:Date of last payment to contractor or finance company Amount of total contract for goods or services:Date contract was entered If you have complained to the contractor or dealership, please summarize their response.Has a lawsuit been filed?YesNoIf a lawsuit has been filed, list the names of the parties, the Court where filed, case number, opposing counsel’s name and contact information, and the amount requested.If a lawsuit was filed, were the parties served?YesNoIf any legal proceedings have been filed, please upload the following Supporting Documents or email to email@example.com. • Lawsuit or other court paperwork, including but not limited to garnishments. • Last account statement received • Any recent correspondence • Copy of Contract for goods or services and other paperwork received. • Repair orders or receipts • Pictures State desired result, i.e. repair, refund, sue, or other remedy.Please tell us about any circumstances that have occurred that may be relevant.Please tell us about any defenses you have to the payment on the contract, if applicable, i.e. improper service, mistaken identity, identity theft, statute of limitations, payment, amount disputed, lack of authority for plaintiff to sue, bankruptcy, unlicensed debt collector, or other excuse to contract enforcement or payment.How did you hear about the Royal Legal Group, LLC?WebsiteInternet searchHyatt Legal PlansARAG Insurance GroupBNIOtherPlease describe how you heard about the Royal Legal Group, LLC below:Disclaimer: If you are sending information and documents to the Royal Legal Group LLC to be reviewed in order to determine if the Royal Legal Group LLC can represent you, the sending of such information and/or documents does not indicate a lawyer-client relationship but merely provides the Royal Legal Group LLC with a means for assessing your case or matter. Such information may also be used to begin drafting any relevant documents necessary to handle your matter.* Yes, I Agree NameThis field is for validation purposes and should be left unchanged.