Citizen Complaint Form

This form is used to submit a formal complaint regarding government services, facilities, departments, or personnel. Please provide all necessary details to ensure your complaint is reviewed and addressed appropriately.

Complainant Information

Full Name: {fullName}

Address: {address}

City: {city}

State: {state}

ZIP Code: {zipCode}

Phone Number: {phoneNumber}

Email Address: {email}

Complaint Details

Date of Incident: {dateOfIncident}

Time of Incident: {timeOfIncident}

Location of Incident: {incidentLocation}

Government Department/Service Involved: {departmentName}

Names of Individuals Involved (if known): {individualsInvolved}

Description of Complaint:

{complaintDescription}

Witnesses

{#witnesses}

• {name}: {contactInfo}

{/witnesses}

Attachments

{#attachments}

• {fileName} - {fileDescription}

{/attachments}

Desired Outcome

{desiredOutcome}

Declaration

I, {fullName}, hereby declare that the information provided in this complaint is accurate to the best of my knowledge. I understand that knowingly providing false information may result in penalties.

Signature: {signature}

Date: {submissionDate}