Complaining Party
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Complaint Against
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Name
|
Name
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Address
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Address
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City StateZip Code
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CityStateZip Code
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Home Phone Number ________________________
Work Phone Number ________________________ |
Preferred method of contact: (circle one)
Home Work |
Have you contacted your local authority? (circle those which apply) Police, Sheriff, District Attorney, Grand Jury
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Have you contacted another state agency? |
___No ___Yes If yes, name of agency _____________________________ |
Have you contacted an attorney?
Is there a court action pending?
|
___No ___Yes
___No ___Yes If yes, name of Court_______________________________
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| Have you lost a lawsuit in this matter? |
___No ___Yes |
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Please provide a factual statement which clearly describes the date, place and nature of the incident which compels you to file a complaint against the above-named party, with this office.
Briefly describe how you believe this office can be of assistance.
___Yes ___No I will sign a sworn statement if required. ____ Check here if additional information enclosed.
Signature ____________________________________
Date ____________________ |
