Complaining Consumer Identification * Required data

Name *
First Lastname *
Second Lastname *
Type of documentation *
Documentation number *
Celphone *
Department *
Province *
District *
Address *
Reference
Email *

Are you a minor?
Yes
No

Detail of the Claim and Consumer Order * Required data

Claim Type *
Type of consumption *
Order No. *
Claim / complaint date
Provider
Reclaimed amount (S/.)
Description of the product or service *
Date of purchase
Date of Consumption
Expiration date
Detail of the Claim / Complaint, as indicated by the client: *
Client order: *
(1) Claim: Disagreement related to products and / or services.
(2) Complain:Disagreement not related to products and / or services; or, discomfort or dissatisfaction with the attention to the public.
I declare that I am the owner of the service and I accept the content of this form by stating under an Affidavit the veracity of the facts described.
* The formulation of the claim does not preclude resorting to other means of dispute resolution nor is it a prerequisite for filing a complaint with Indecopi.
* The provider must respond to the claim within a period of no more than thirty (30) calendar days, being able to extend the period up to thirty days.
* By signing this document, the client authorizes to be contacted after the claim has been dealt with in order to evaluate the quality and satisfaction with the claims service process.
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