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WHISTLEBLOWER PROTECTION AND REPORTING POLICY COMPLAINT FORM (Optional) Name: (Optional) Address: (Optional) Work Phone: (Optional) Home/Cell Phone: Are you a City of Lewiston employee? Yes No If yes, what is your position or relationship to the City? 1. Identify the person or persons against whom your allegations are made. 2. Describe the nature of your complaint, the incident(s) or event(s), date(s), time(s), and place(s). Attach additional pages to this complaint if necessary. 3. Identify others who may have observed or witnessed the incident(s) that you described. 4. Do you have any documents that support your allegation? (Please list and attach copies). For All Complaints NOT INVOLVING the City Administrator You may complete/mail this form to City Administrator, Lewiston City Hall, 27 Pine Street, Lewiston ME 04240 or email it to [EMAIL REDACTED]. If you are submitting this form through the City Administrator’s web page, the online form will be automatically forwarded to the City Administrator when you click “Submit.” For All Complaints INVOLVING the City Administrator Mail this form to Martin Eisenstein, Esq., Lewiston Whistleblower Program, P.O. Box 3070, Lewiston, ME 04243-3070. 7 Adopted 12/04/2012