Ombudsman Complaint Form

Name

(First)

(Last)

Street Address

City

State

Zip Code

Phone Number

E-Mail Address

Please enter N/A where not applicable.

Against which individual program practice or process do you wish to complain?

When did it come to your attention?

What is the decision or matter about which you complain?

What result do you hope to achieve with your complaint?

Have you already contacted the Department in order to resolve the problem?

Yes

Who was contact? When were they contacted? What happened?

Do you agree that your complaint may be passed on to another authority if the Ombudsman decides that he is not the appropriate person to deal with it?

Yes

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Ombudsman Complaint Form