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Taxi Complaint Form
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Contact Information
First Name*
Last Name*
Primary Phone Number*
Secondary Phone Number
Email Address*
Incident Details
Taxi Company Name*
Taxi Vehicle Number
Driver Name
Chauffeur's Registration Number
Date of Incident
Date of Incident*
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Time of Incident
Pick Up Location*
Pick Up Time
Drop Off Location*
Drop Off Time
Incident Description*
Attach a File (relevant documents, receipts, photos, etc. - .exe files are not permitted)
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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 penalty 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. I understand further that my complaint is a public record.
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