Note: Any inmate over the age of 21 will be contacted for his/her consent before the Department of Corrections proceeds with any investigation.

Date_________________

Name of Inmate__________________________________

CDC No.____________________

Your Name______________________________

Your Relationship to Inmate______________________________________

Your Mailing Address_____________________________________________

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Your Phone No.___________________________________________________

Please Describe Your Complaint (attach additional sheets or use page 2 if necessary.)

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What Attempts Were Made by the Inmate to Resolve the Problem?

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Have You Spoken to the Inmate About this Problem? Yes No

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Please Use This Page For Additional Comments If Necessary:

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