Filing Complaint Form

Filing Complaint Form

Complainant and Respondent Information

Date of Incident:    Time of Incident:

WHEREAS

WHEREAS, Complainant: alleges that Respondent: engaged in conduct that has caused harm, loss, or breach of obligations described herein;

WHEREAS, the parties seek to document the factual basis of the complaint and, where practicable, propose or record terms for resolution, including remedies, payments, confidentiality, and related terms; and

WHEREAS, the completion and filing of this form constitutes a formal written complaint submitted by Complainant and may be used to initiate investigation, dispute resolution, or negotiation between the parties.

Complaint Details

Supporting Documentation

Please indicate documents submitted with or referenced by this complaint:

Photographs

Contracts or Agreements

Invoices or Bills

Other:

Relief Requested and Proposed Resolution

If the parties agree or propose a negotiated resolution, proposed payment terms and scope are set out below. Completing these fields does not constitute acceptance by the other party unless signed in the signature block below.

Scope of Work (Proposed or Agreed Actions)

Payment Terms (If Applicable)

Total Amount Proposed: $

Late Fee or Interest on Overdue Payment:

Term and Termination

Proposed Term Start Date:    Proposed Term End Date:

Notice Period for Termination (number of days):

Confidentiality

Except as required by law, the parties agree that any settlement terms, financial amounts, or proprietary information disclosed in connection with this complaint and any resulting resolution shall be held in strict confidence and shall not be disclosed to third parties without prior written consent of the other party.

Complainant requests that confidentiality terms apply to this filing and any negotiated resolution.

Governing Law and Entire Agreement

This complaint form, and any resolution or agreement executed between the parties in connection with this complaint, shall be governed by and construed in accordance with the laws of the state of , without regard to conflict of law principles.

The parties acknowledge that any signed resolution of this complaint constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior agreements and understandings, whether written or oral.

Certification and Attestation

I declare under penalty of perjury under the laws of the governing jurisdiction that the information contained in this complaint is true and correct to the best of my knowledge, and that I am entitled to bring this complaint or am authorized to file on behalf of the named Complainant.

I attest that the above statements are true and correct.

Additional Information

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