File a Complaint

Your Name:

First Name   Last Name 

Email Address:

Email  *
Email Example (john.doe@help.com) Required

Address:

Street   City  

State               Zip  

Are you a state employee? *
Yes
No

If so, what agency?

Phone Number:

Home Phone   Work Phone   

Cell Phone     

County:

Name of person(s) and agency involved in alleged wrongful act or omission.

Name: *

First Name   Last Name 

Position/Title:
 

Agency: *

Division:

Address:

Street  City 

State                                  Zip  

Summary of facts relevant to the allegations:

Information that is helpful includes: What is the problem? Who is involved? When, where and why did it happen? *

Other helpful information (if known):

Has this complaint been filed with any other agency or investigative entity? *

If Yes, what is the name of the agency?

Date Filed:

List any action taken by that agency:

Has a lawsuit and /or administrator grievance been filed against this agency/individual based on the allegations in this complaint? *

If yes, what is the name of the court and status of the case?

Are there any documents regarding the alleged wrongful act of omission? (i.e., contracts memos, letters, evaluation forms, minutes of meetings, etc.) If so, describe and /or attach them to this form.

Attach relevant documents:

Provide the name(s) of other people we may contact with knowledge of the alleged wrongful act or omission. Include the address and phone number of such person(s).

Is your allegation related to funds from the American Recovery and Reinvestment Act (Stimulus Plan) of 2009?

Please be specific on how the funds related to the entity/program you are reporting is related to the American Recovery and Reinvestment Act (to incluce others who may have specific information and/ or documents related to your allegation).

Which best describes the subject of your allegations?