Santa Clara — AD-1022

Source: https://santaclara.courts.ca.gov/system/files/forms/ad-1022_rem.pdf

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SANTA CLARA COUNTY CIVIL GRAND JURY COMPLAINT FORM

To: Santa Clara County Civil Grand Jury IMPORTANT: The Grand Jury does not Superior Court of California, have authority to investigate complaints County of Santa Clara involving State or Federal government 191 North First Street agencies, non-governmental entities, or San Jose, California 95113 matters outside Santa Clara County. The 408-882-2721 Grand Jury does not investigate all CGJ@scscourt.org complaints received.

From:

Your Name:

Mailing Address: City: Zip:

Day Phone: ( ) Email Address:

This complaint is against:

Name, Title, Agency:

Mailing Address: City: Zip:

Phone: ( )

Complaint: Be specific; include names and dates. Describe the problem in your own words. All information is confidential. You may attach additional pages as necessary.

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AD-1022 REV 1|)(|(1 Page 1 of 2

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Please describe any previous attempts to resolve this complaint, including the agencies you contacted and the action taken by the agencies. You may attach additional pages as necessary.

How would you like to see this matter resolved? You may attach additional pages as necessary.

I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

SIGN

Signed: Date:

SUBMIT

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