Complaint Form - Bureau of Medi-Cal Fraud and Elder Abuse - California Dept. of Justice

Office of the Attorney General, Department of Justice

OFFICE OF THE AG

Bureau of Medi-Cal Fraud and Elder Abuse
Complaint Form

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	State of California Attorney General Bill Lockyer Complaint Form (Print Form, Fill Out, and Mail)	Department of Justice Public Inquiry Unit P.O. Box 944255 Sacramento, CA 94244-2550 (916) 322-3360 (800) 952-5225 California only
I wish to file a complaint against the party named below. I understand that the Attorney General does not represent private citizens seeking private remedies. I am, however, filing this complaint to notify your office of my allegations so that it may be determined if a law enforcement or statewide legal action is warranted.

Complaining Party

Complaint Against

Name

Address

City

State

Zip Code

City

State

Zip Code

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
Have you contacted another state agency?		___No ___Yes
If yes, name of agency _______________________
Have you contacted an attorney?		___No ___Yes
If yes, name of agency _______________________
Is there a court action pending?		___No ___Yes
If yes, name of agency _______________________
Have you lost a lawsuit in this matter?		___No ___Yes

Please provide a factual statement that clearly describes the date, place, and nature of the incident that 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.

I will sign a sworn statement if required.___Yes ___No

____ Check here if additional information enclosed.

Signature ____________________________________ Date ____________________