Appendix C-3: Sample Complaint Form

In the sample complaint below, instructions are in bolded green text to indicate where you need to add information. You can copy and paste the sample form below or download the editable complaint form.



I am hereby filing a complaint regarding the problems described below. I request that you or the appropriate member of your agency take action to remedy the situation as soon as possible. I also request that you contact me regarding the resolution of this complaint.

This Complaint is submitted by:

Name: [Insert your name]

Phone: [Insert your phone number]

E-mail: [Insert your e-mail]

Date: [Insert date submitted]

Time: [Insert time submitted]

Description of the Problem:

Could this problem involve issues of public health? Yes / No


Erosion/Sediment ___ Water Quality ___ Sewage Spills ___
Buffers ___ Stormwater/Flooding ___ Land Usage ___
Rezoning Land Usage ___ Spills ___ Air Pollution ___
Dumping ___ Other ___

Description: [Insert brief description of the complaint]

First noticed: [Insert date you first noticed the problem]

Is the violation ongoing? [Answer whether the issue is ongoing]

Location: [Insert the location of the problem]

Other Information: [Insert any other information relevant to the problem]

Other government agencies reported to: [List any other agencies you reported the problem to]