Personal Information

Name
Title
Address
Phone

Reporting Agent

Name of Agent/Representative/Person preparing complaint (if different from Complainant):

Information on Incident

Include in your response the identity of the service, activity, program, or benefit at issue. Please also provide in your description specific dates, times, and places, as well as the names, addresses, and telephone numbers of any and all persons who may have witnessed or been involved in the act or basis of your complaint. (Attach additional information, if needed)
One file only.
8 MB limit.
Allowed types: gif jpg png txt rtf html odf pdf doc docx xls xlsx xml .
Are the circumstances continuing?
Have you filed a complaint with any other Federal, State, or local agency or court?