Make a Complaint

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What is your complaint about?

What agency (or agencies) are you complaining about?

Personal Details

Title* --- Mr. Mrs. Miss Ms. Dr.

First Name(s) *

Last Name *

Mailing Address *

City *

State *

Zip Code *

Phone * --- Home Mobile Work Fax

Alt Phone * --- Home Mobile Work Fax

Email *

If you are complaining on behalf of someone else, who is it?

What is your relationship to this person?

Please tell us more about your complaint

Summarize any other information that you feel might be relevant to your complaint. *

Supporting material

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How are you sending the supporting material?

(If sending material by post or fax please label clearly with your personal details)

By mail: Dayton Ombudsman Office, 11 West Monument Ave., Suite 606, Dayton, OH 45402
By fax: 937-228-1183

Other Information

Answering the following questions is optional but your answers will help us improve our service delivery.

How did you hear about the Ombudsman? --- Newspaper DATV Program General Knowledge/Previous Contact Government Agency Internet Lawyer Community Organization Church Family/Friends Word of Mouth Other

If "Other", what?