Form MCSA-2P Household Goods\Commercial Complaint Form

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork
Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0025. Public reporting for this collection of information is estimated to be
approximately 10 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are voluntary,
and will be provided confidentiality to the extent allowed by the Freedom of Information Act (FOIA).. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing
this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.

OMB No. 2126-0025
Expiration Date:

UNITED STATES DEPARTMENT OF TRANSPORTATION
FEDERAL MOTOR CARRIER SAFETY ADMINISTRATION

Household Goods\Commercial
Complaint Form
Instructions: Fill out all of the information in the following form to file a consumer complaint. Required
information is indicated by a asterisk (*) next to the input box. When finished click the Validate button at the
bottom of the form, if any problems are detected with the inputted information a list of error will be displayed
to you.

Report Date:
Name:(*)

Complainant Type:

Address:(*)

Shipper

City(*)

Carrier
~

..... State/province

ZIP(*)

Freight Forwarder
Broker

Email
USDOT #:

Other

MC#:

You can use Safersys.org to retrieve Respondent Information.
Name

Respondent Type:

.

Motor Carrier - Property
Motor Carrier-Household Goods

City*

State* :

Zip*
Telephone*:

Freight Forwarder
Freight Forwarder Household

Fax No:

Goods Broker Property
Broker Household Goods
Shipper/Receiver (Lumping)

Email:

Owner/Operator

Motor Carrier - Passenger
Mexican Motor Carrier
Lumper - Unloading

Use www.saferysys.org to search for respondents USDOT
or MC numbers.

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Form MCSA-2P

MC#:

Secondary Respondent Name
USDOT#:
MC#:

Household Goods

Loss / Damage

Personal Automobiles

Estimate/Final Charges

Claim Settlement

Lumper Loading/Unloading

Property Brokers

Weight

Unauthorized Operations

Other

Pick-up/Delivery
Hostage

Owner-Operations Leasing
Pickup Location(*):

Delivery Location(*)

Pickup Date:

Delivery Date Or Expected Delivery Date:

Shipping/Invoice/Billing #:
Description Of the Complaint:(*)

Form MCSA-2P

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