Great as a general complaint template, this adjustment form can be filled in by unhappy clients and customers.
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| Name of Complainant | |
| Date of Complaint | |
| Name and Location of Store/Company | |
| Name of Responder | |
| Date of Response | |
| Adjustment Requested | |
| Approved Adjustments | |
| Rejected Adjustments | |
| Effective Date | |
| Refund/Compensation Amount | |
| Name of Recipient | |
| Phone Number of Recipient | |
| Address of Recipient | |
| Received and Recorded by | |
| Date | |
