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Passenger Transportation Complaints
Passenger's Contact Information
Temporary Complaint No.*
(Use last 4 digits of your home telephone number)
First Name*
Last Name*
Address*
City*
State*
Zip*
Primary Phone Number*
Secondary Phone Number
Email Address*
Date of Incident
*
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Driver and Vehicle Information
Time of Incident*
(xx:xx)
Point of Pick Up*
Destination*
Driver Name
Driver Registration Number
Company Name
Phone Number
For-Hire Vehicle Number
Tag Number
Description of Driver
Description of Incident
*
How would you like your complaint resolved?
Attach a file (relevant documents, receipts, photos, etc. - .exe files are not permitted)
Drop files or click here to upload
Do you have another photo /document to add? If so, attach here. (relevant documents, receipts, photos, etc. - .exe files are not permitted)
Drop files or click here to upload
By clicking the checkbox, I agree:
By submitting this complaint affidavit, I understand that whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the performance of his or her official duty shall be guilty of a misdemeanor of the second degree, punishable as provided in Florida Statutes.
By clicking the checkbox, I agree:
By submitting this complaint affidavit I declare, under penalties of perjury, that I have read the foregoing complaint affidavit, that the facts stated in it are true and that any supporting documentation I submit will be copies of genuine documents.
By clicking the checkbox, I agree:
By submitting this complaint affidavit, I understand my complaint is a public record and that a copy of this complaint will be sent to the merchant for their response.
An electronic signature has the same force and effect as a written signature, pursuant
to Section 668.004, Florida Statutes
*Required Fields
By submitting this complaint affidavit I declare, under penalties of perjury, that I have read the foregoing complaint form, that the facts stated in it are true and that any supporting documentation I submit will be copies of genuine documents. I understand further that my complaint is a public record and that a copy of this complaint will be sent to the business/transportation operator for their response.
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