Form Builder

Reporter's Contact Information:

Title:

First Name:

Last Name:

Phone #:

Phone Type:

Email:

Mailing Address:

City:

State:

ZIP:

Business/Individual Violating Price Gouging Law:

Entity Type:

Price Gouging Location:

Location Information:

Business Name

City:

State:

ZIP:

Business Phone #:

Business Website:

Online Business Information:

Online Business Name:

Seller's Name/Username/Account:

Business Website or Link to Page (if applicable):

Social Media Information:

Platform Information:

Other:

Seller's Name/Username/Account:

Link to Page (if applicable):

Description of Price Gouging Incident:

Date Price Gouging Observed:

Description of Product:

Quantity & Size of Item:

Inflated Price (on or after 3/11/20):

Standard Price (before 3/11/20):

Upload Supporting Documentation (photos, screenshots, etc)