Describe the events which led to your complaint and specify pertinent dates, monies paid, balances
owed, amounts claimed by third parties, etc. Use additional sheets if necessary. Attach any
documentation such as plans, contracts, proposals, communication, drawings which will help support
your complaint. The filing of this complaint does not prohibit you from filing a civil action.
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I certify under penalty of perjury under the laws of the State of California that to the best of my knowledge the
information contained in this form is true and correct. If called upon, I will assist in the investigation or in the
prosecution of the Subject or other involved parties, and will, if necessary swear to a complaint, attend hearings
and testify to the facts of this complaint.
Signature:___________________________________________________________________
Date:__________________________
Rev. 02/17