Make a Complaint Form

Make a Complaint

Required information shown with *
What is your complaint about?
What agency (or agencies) are you complaining about?
Personal Details
Title *
Name *

First NameLast Name
Mailing Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Alternate Phone Number *
Please enter a valid phone number.
Email *
example@example.com
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
Choose File

Cancelof
How are you sending the supporting material? (If sending material by post or fax please label clearly with your personal details)

Mail: Dayton Ombudsman Office, 11 W. Monument Ave., Ste 606, Dayton, OH 45402Fax: 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?
If "Other", what?
Should be Empty: