FOR OFFICE USE ONLY

DATE RECEIVED: _____________

CASE NUMBER: _______________

COMPLAINT

ALLEGING FAILURE OF DEPARTMENT OF JUSTICE EMPLOYEE

TO PROVIDE RIGHTS TO A CRIME VICTIM UNDER

THE CRIME VICTIMS' RIGHTS ACT OF 2004

Return the signed complaint, including any additional pages or documents, directly to the Department of Justice component, or local United States Attorney's Office, that is named in your complaint. If you do not know where to send the complaint, you may send it directly to the Office of the Victims' Rights Ombudsman, who will forward your complaint to the office that is the subject of your complaint.	Victims' Rights Ombudsman

Executive Office for United States Attorneys

Department of Justice

2261 RFK Main Justice Building

950 Pennsylvania Ave., N.W.

Washington, DC 20530-0001

Fax: (202) 305-4937

This Complaint form is not designed for the correction of specific victims' rights violations, but is instead to request corrective or disciplinary action against Department of Justice employees who may have failed to provide or have violated the rights of a crime victim under the Crime Victims' Rights Act of 2004. A crime victim includes any person who has been directly and proximately harmed as a result of the commission of a Federal offense or an offense in the District of Columbia.

All complaints must be submitted within sixty (60) days of the victim's knowledge of a violation by the Department of Justice employee, but not more than one year after the actual violation. Receipt of complaints will be acknowledged in writing.

The information provided herein will be used along with other information developed during the investigation to resolve or otherwise determine the merits of this complaint. The information may be furnished to designated officers and employees of agencies and departments of the Federal Government in order to resolve or otherwise determine the merits of this complaint.

Please check the box that applies to the person filing this complaint.

□	Victim	□	Attorney representing victim

□	Legal Guardian	□	Other representative (describe) ___________________________

Name, phone number and relationship to victim of person completing this form (if not the victim).

Is the victim represented by an attorney in this complaint? □ Yes □ No

If yes, please provide the attorney's name and contact information. All future contacts with the victim regarding this complaint will be made through the attorney.

1.	PERSONAL INFORMATION ABOUT THE VICTIM

First Name:	Middle Name:	Last Name:
Title: Mr. ___ Mrs. ___ Ms. ___ Miss ___ Other ___
Street Address:
City:	State:	Country:	Zip Code:
Home Telephone No:	Work Telephone No:	Cell Phone No:
Email Address:

2.	INFORMATION ABOUT THE CRIMINAL CASE

The following section requests important information about the criminal investigation or case in which you are a victim. Please provide as much information as you can.

Stage of the Criminal Justice Process - Select most recent event:

□ Investigation □ Arrest □ Arraignment □ Preliminary Hearing □ Guilty Plea □ Trial □ Sentencing □ Parole Hearing

□ Other ________________________________________
Defendant(s) Name(s):
Case Number:	District Court:	Judge:

3.	INFORMATION ABOUT THE VICTIM'S COMPLAINT

What is the location and name of the office(s) or organization(s) of the Department of Justice that is/are the subject of your complaint?

Is your complaint against a specific person in that office? □ Yes □ No

If yes, please identify the person(s) (include position or title, if known) who failed to provide the right(s) about which you are complaining.

Which of the following rights afforded by the Crime Victims' Rights Act of 2004, 18 U.S.C. § 3771, do you feel you were denied? Please check all that apply.

□	The right to be reasonably protected from the accused.

□	The right to reasonable, accurate, and timely notice of any public court proceeding, or any parole proceeding, involving the crime or of any release or escape of the accused.

□	The right not to be excluded from any such public court proceeding, unless the court, afer receiving clear and convincing evidence, determines that testimony by the victim would be materially altered if the victim heard other testimony at that proceeding.

□	The right to be reasonably heard at any public proceeding in the district court involving release, plea, sentencing, or any parole proceeding.

□	The reasonable right to confer with the attorney for the Government in the case.

□	The right to full and timely restitution as provided by law.

□	The right to proceedings free from unreasonable delay.

□	The right to be treated with fairness and with respect for the victim's dignity and privacy.

4.	STATEMENT OF COMPLAINANT

Please provide as much detailed information about your complaint against the Department of Justice employee(s) as possible, including the date(s) of the alleged violation(s), and an explanation of how the violation(s) occurred. However, you should not discuss the facts of the criminal investigation or case in which you are a victim. You may attach additional pages or documents to this complaint.

5.	PRIOR NOTIFICATION TO THE DEPARTMENT OF JUSTICE

Although you are not required to do so, did you notify the Department of Justice employee, or any employee of the office described above, of the alleged violation before filing this complaint? □ Yes □ No

If yes, please describe your efforts to resolve this matter, including the date(s) that you notified the Department of Justice employee or any employee of the office described above; the name, address and telephone number of the person with whom you attempted to resolve this matter; and the actions taken by the Department of Justice employee or office to resolve your complaint. You may attached additional pages or documents to this complaint.

6.	OTHER RELEVANT INFORMATION

Provide any other relevant information or event(s). You may attach additional pages or documents to this complaint.

The information set forth herein is true and correct to the best of my knowledge.

Signature:	________________________________________	Date: ____________________________

(Must be signed by Victim)

If the crime victim is under 18 years of age, incompetent, incapacitated, or deceased, this form must be signed by the Legal Guardian of the crime victim or the representative of the crime victim's estate, family member, or any other person appointed by the court. Please check all that apply to the victim:

□ Under 18 years of age	□ Incapacitated	□ Incompetent	□ Deceased

Signature:	________________________________________	Date: ____________________________