NEBRASKA DEPARTMENT OF JUSTICE OFFICE OF THE ATTORNEY GENERAL …

     NEBRASKA DEPARTMENT OF JUSTICE OFFICE OF THE ATTORNEY GENERAL
                    CONSTITUENT COMPLAINT FORM
Please Print or Type.                        Complaint Reported By                                   Date Mailed: _____________


Name: _____________________________________________                                Date of Birth: _____/_____/______
          Last                   First                    M

Address: ___________________________________________                               Hours Available: ______________

                                                                                 If At Work, When: _____________
City: _______________________ State: ______ ZIP: _________          County: ___________________

Place of Employment: __________________________________

Address: _____________________________________________                         Phone: Hm: _______________________
                                                                                      Wk: _______________________
City: _______________________ State: ______ ZIP: _________          County: ___________________


                                          Complaint Reported Against

Name: __________________________________________               Place of Employment: ______________________________
          Last                First                 M
                                                               Position: ________________________________________
Address: ________________________________________              Address: ________________________________________
           (If Known)

City: _______________________ State: ________                  City: ___________________________ State: ___________
ZIP: ____________County: __________________                    County: ________________________ ZIP: ____________

                                                        Witnesses

Name: __________________________________________               Name: __________________________________________
          Last                First                 M                           Last                           First              M

Address: ________________________________________              Address: ________________________________________
           (If Known)                                                                  (If Known)

City: _________________________ State: _________               City: _____________________________ State: _________
County: ___________________ Phone: Hm: _____________           County: __________________ Phone: Hm: _____________
                                   Wk: _____________                                             Wk: _____________

Name: __________________________________________               Name: __________________________________________
          Last                First                 M                    Last                          First                  M

Address: ________________________________________              Address: ________________________________________
           (If Known)                                                      (If Known)

City: _________________________ State: _________               City: _____________________________ State: _________
County: ___________________ Phone: Hm: _____________           County: __________________ Phone: Hm: _____________
                                   Wk: _____________                                             Wk: _____________



 Have you filed reports with any other agency regarding         Has any action been taken against you regarding this matter,
 this matter? IF YES: ______________________________            Please circle: Arrest               Conviction         Citation
                        ______________________________
                                                                Has any action been taken against the subject in this matter,
                        ______________________________
                                                                Please circle: Arrest               Conviction         Citation
 Agency/Date(s)         ______________________________
                        ______________________________
Describe the facts which have led to the filing of this complain and include, if possible, exact dates and locations
of pertinent events. Please attempt to put in chronological order. This complaint will be photocopied.
PLEASE PRINT or TYPE ALL INFORMATION. Use additional paper if needed.

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The information given above is true to the best of my knowledge and belief. I authorize the Nebraska Attorney
General's Office, or its designate to use this information given, in any manner which is determined necessary.

                 ____________________________________       _____________________
                             Signature                                       Date
                                       Return Completed Form to:
                                       Nebraska Attorney General
                                           2115 State Capitol
                                        Lincoln, NE 68509-8920
                                     ATTN: Law Enforcement Division
Revised 5/2007                                   Fax: (402) 471-3297