Customer Complaint Form - Department Of Human Services Dane County

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DANE COUNTY DEPARTMENT OF HUMAN SERVICES
CUSTOMER COMPLAINT FORM
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If you need assistance in completing this form, please call 242-6481
Return Completed form to: Adult Community Services Division
Administrator, Fran Genter, 1202 Northport Drive, Madison, WI 53704
COMPLAINT INFORMATION:
Name: _________________________________________________________________________________
Address: _______________________________________________________________________________
City, State, Zip: _________________________________________________________________________
Home Phone: _____________________________ Work Phone: ________________________________
Describe your complaint below (if you need more room, please use the back side or attach additional sheets). State all
facts, including date of incident and time, place of incident, names of others involved, witnesses (if any), what actions
have you taken up to this point, and action you wish the Department to take.
Signature of Complainant: _____________________________________________ Date: _______________
Complaints are protected from retaliation by state law.

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