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NOTE: This form and its contents, upon submission to the Commission, shall become a public record subject to disclosure to members of the public upon request as provided in the New Mexico Inspection of Public Records Act (NMSA Sections 14-2-1 through 14-2-12). City of Farmington Community Relations Commission P.O. Box 192, Farmington, NM 87499 Message Center: 599-8442 COMPLAINT FORM Name Phone Address City State Zip E-mail If needed, name of person who knows where to contact you: Phone Address Name of person, agency or institution you are filing a complaint against Address City State Zip Phone Is this address within the Farmington City limits? Date Problem Occurred Date(s) You Complained to Person/Agency To Whom Name of Employee at Agency/Institution this complaint is against Have you filed a complaint with any other organization, court or governmental organization? (check one) If yes, please provide the information below. Name Date Complaint Filed Status of Complaint What remedy are you seeking? I swear or affirm the attached complaint is true to the best of my knowledge and information. I also acknowledge that I may be required to attend a meeting or hearing as part of the investigation of my complaint. Your ---PAGE BREAK--- Community Relations Commission ◘ P.O. Box 192, Farmington, NM 87499 ◘ Message Center: 599-8442 Witness Information (if any) Name Phone Address City State Zip E-Mail Name Phone Address City State Zip E-Mail Name Phone Address City State Zip E-Mail Name Phone Address City State Zip E-Mail Name Phone Address City State Zip E-Mail ---PAGE BREAK--- Community Relations Commission ◘ P.O. Box 192, Farmington, NM 87499 ◘ Message Center: 599-8442 City of Farmington Community Relations Commission Write in chronological order the events that took place, and what steps you have taken so far. If you need additional room, please use the back of this form or attach additional pages. Include the name of the organization’s representative that you have been dealing with. Please provide information and witnesses that are relevant to the situation, and attach copies of any paperwork you may have. If you have witnesses, please provide their information on the next page. Please keep a copy of this complaint for your records. Received Date