1. Describe specifically your complaint, including whenever possible, dates, names, offices or departments involved in your complaint.
2. Describe any efforts you have made to attempt to resolve the issue or concerns that are included in your complaint. What was the outcome of this effort?
3. What, if any, resolution or outcome are you seeking as a result of this complaint?
_____________________________________________________________
Name
_____________________________________________________________
Address
_____________________________________________________________
Signature
______________________________
Phone Number
______________________________
Date
Office Use Only:
Date of Receipt: _________________________
Received by: _________________________________________________
