A Contractor

My Complaint Involves

A Lender

Your complaint will be processed most efficiently if you can provide the last four digits of your local NRIA Authorized Contractor or Lenders number which is located on any notice(s) you may have received from us. If you know the last four digits of your local NRIA Authorized Contractor or Lender, please enter them in the field provided.

Last four digits of NRIA Contractor/Lender Code (Optional)

Contractor or Lender’s Company Name

Your Contact Information

Title

First Name

Middle Name

Last Name

Suffix

Address

Address 2

City

State

Zip

Daytime Phone

Evening Phone

Fax Number

E-Mail Address

Please provide a brief, factual description of the problem you experienced:

Primary Classification

Secondary Classification

Tell us about your problem: (Please limit your response to the approximate amount of text that will fit in the box below, without scrolling)

Complaint Background

The following questions are not mandatory, however, we do ask that you provide as much information as you have available.

Product/Service Purchased

Model Number(s)

Contract/Account/Policy #

Order #

Purchase Date (mm/dd/yyyy)

Date Problem Occurred

Date(s) you complained to the company

First Date (mm/dd/yyyy)

Second Date (mm/dd/yyyy)

Third Date (mm/dd/yyyy)

Payment Made?

Name of Salesperson

Title

First Name

Middle Name

Last Name

Suffix

Purchase Price

Disputed Amount

Desired Outcome

Enter your desired outcome below. Please keep your description within the box provided, without scrolling. A summary of your complaint is preferred, as an NRIA representative will contact you if additional details are needed.

Desired Settlement

What is your desired outcome?

Please use the scroll bar on your web browser to review all of the information you have provided. If all information is correct, click the submit button below to submit your complaint.