Tobacco Sales Complaint Form

Reminder you have to be 21 years of age or older to purchase tobacco products, electronic cigarette products or nicotine products! “Please use this form to report illegal sales of tobacco products, electronic cigarette products, and nicotine products whether online, by phone or in-person. Please fill out as much information as possible. If you do not have the information needed you can skip to the next question.”

How did the Sale Occur?
How did the illegal sale occur?	Online Sale Phone Sale Physical Location (excluding retailer) Physical Location at Retailer Online – No sale just know they are selling online Phone – No sale just know they are selling by phone
Which best describes you?	Concerned Citizen Parent Friend School Administrator Other
Describes you: Other
When did the Sale Occur?
Approximate Sale Date
Approximate Sale Time
Product Purchased
What Product(s) was Purchased?	Tobacco Product (cigar, cigarettes, chewing tobacco, etc) E-Cigarette Product (JUUL, e-liquid, etc) Nicotine Product (see description below) Other
* Tobacco Product: cigar, cigarettes, chewing tobacco, snus, etc * E-Cigarette Product: JUUL, e-liquid, cartridge, pod, etc * Nicotine Product: pure nicotine, dissolvable salts, orbs, pellets, toothpicks, nicotine-laced food and beverage, inhaler (not FDA approved NRT)
Description of product(s) purchased: (brand name, nicotine concentration level, etc)
Pay for Product
How did the person pay for the product?	Venmo Paypal Cash app Credit Card Gift Card Cash Other Unknown
Photo of receipt
Other Documentation
Activity Occurring
How did you know this activity was occuring?
Are you willing to speak to a representative at Utah Department of Health or your Local Health Department for more information?	Yes – Department of Health Yes – Local Health Department Yes – Both No
Contact Information
Name (Optional)
Phone Number (Optional)
Phone Number Extension (Optional)
Email (Optional)
If you prefer not to give your Name, Phone, or Email, how may we contact you?
Buyer Description
What is the age of the buyer?	List specific age Unknown but appears younger than 21 Unknown but appears to be 21 years old or older
Age of Buyer:
Gender	Male Female Unknown
Description of the underage buyer: (i.e. approx. height, hair color, other markings, etc)
Retailer Web
Retailer Website
Retailer Social Media	Facebook Instagram SnapChat TikTok Twitter Telegram YouTube Other
Retailer Social Media Handle
Retailer Information
Retailer Business Name
Description of Sales Clerk: (i.e. approx, age, sex, height, hair color, other markings, etc or UNKNOWN)
Retailer Phone Number
Retailer Phone Number Extension
Retailer Physical Address
State/Region	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Thank you, your complaint has been submitted!