................... , on ............... 20....... COMPLAINT FORM Name and surname: .............................................. ..................................................... _ ..................................................... ...... Address:  .................................... ..... .............................................. ....... ..................................................... ........... . e-mail:  .................................... .... ................................... ........ ..................................................... ........... phone: ..................................... ....................................................... _ ..... ................................................ .............................. Bank account number: ................ .............................. ................................... ................................................... _ .................... SUBJECT OF THE COMPLAINT: Date of purchase of the goods : ....................... ................................................... _ ..................................................... _ ............... Name of the goods:  ......................................................... ...... ........................................................ _ ................................................. Receipt number / invoices : .................................................. ......................................................... ...... .......................................... Total value of goods: . . ..................................................... ....................................................... _ .....................................
SUBMISSION OF A COMPLAINT ( description of defects and circumstances of their occurrence ): ................................... ...................................................... _ ...................................................... .... _ .......................................
.................................... .... .................................... ..... ..................................................... _ ................................... ................... ................................................... _ ..................................................... _ ..................................................... _ ............... ................................................ ........ .......................................... ...................................................... ... _ ......................................... REPAIR ACTIONS/DEMAND OF THE COMPLAINTER: (___) replacement of the item with a defect-free item, (___) removal of the defect, (___) price reduction, (___) withdrawal from the contract. (legible signature of the advertiser)