Claims Book

CONSUMER IDENTIFIER COMPLAINANT/COMPLAINANT

Natural Person Legal Entity

First and Last Names:

Identity Doc:

Company name:

N. Document:

Department:

Province:

District:

E-mail:

Date of incident:

Amount of the good or service:

Guide or tracking number:

CONSUMER COMPLAINANT/COMPLAINANT'S MANIFESTO

Type

Complaint Claim

Contracted asset

Product Service

Proof of Payment:

Voucher No:

Headquarters/Branch:

Product or Service Detail

Details of the Complaint or Grievance

I declare that I am the owner of the contents of this form, declaring under sworn statement the facts described in it.

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