DMFEA Fraud and Abuse Complaint Form | State of California - Department of Justice

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<ol class="breadcrumb"><li><a href="/">Home</a></li> <li><a href="/dmfea" class="active-trail">DMFEA</a></li> <li class="active">DMFEA Fraud and Abuse Complaint Form</li> </ol> <div class="region region-content"> <div id="block-system-main" class="block block-system"> <div class="content"> <div id="node-471" class="node node-webform clearfix" about="/dmfea/reporting" typeof="sioc:Item foaf:Document"> <span property="dc:title" content="DMFEA Fraud and Abuse Complaint Form" class="rdf-meta element-hidden"></span><span property="sioc:num_replies" content="0" datatype="xsd:integer" class="rdf-meta element-hidden"></span> <div class="content clearfix"> <form class="webform-client-form webform-client-form-471" action="/dmfea/reporting" method="post" id="webform-client-form-471" accept-charset="UTF-8"><div><div class="form-item webform-component webform-component-markup webform-component--intro-text form-group form-item form-type-markup form-group"><p align="right"> <span title="Spanish"><a lang="es" href="/dmfea/reporting#googtrans(en|es)" target="_blank">En español</a></span>   |   <span title="Chinese" style="font-family: Arial Unicode MS;"> <a lang="zh" href="/dmfea/reporting#googtrans(en|zh-CN)" target="_blank">中文</a></span>   |   <span title="Vietnamese"><a lang="vi" href="/dmfea/reporting#googtrans(en|vi)" target="_blank">Tiếng Việt</a></span>  <br /> <a href="/disclaimer#google">Google Translate Disclaimer</a></p> <p style="font-size:1.3em;">To report suspected Medi-Cal fraud or elder abuse, consider these options:</p> <h3 class="complaint">Send A Written Complaint By Mail</h3> <p class="address"> California Department of Justice<br /> Division of Medi-Cal Fraud Elder Abuse<br /> P.O. Box 944255<br /> Sacramento, CA 94244-2550 </p> <h3 class="complaint">Call the Complaint Line</h3> <p class="address"> <strong>Phone Toll-free: (800) 722-0432</strong><br /> Attorney General's Division of Medi-Cal Fraud & Elder Abuse </p> <p class="address"> <strong>Phone Toll-free: (800) 822-6222</strong><br /> Department of Health Services </p> <h3>Or Email Your Complaint Using This On-line Form</h3> <p>I want to report suspected Medi-Cal fraud or elder abuse. I understand that the Attorney General does not represent private citizens seeking private remedies. I submit my allegations for review to determine if law enforcement or statewide legal action is warranted.</p> <p><img src="/sites/all/files/agweb/images/backgrounds/required-red-star.gif" alt="required" /> Indicates Required Fields </p></div><fieldset class="webform-component-fieldset webform-component--complaining-party panel panel-default form-wrapper" id="bootstrap-panel"> <legend class="panel-heading"> <span class="panel-title fieldset-legend">Complaining Party</span> </legend> <div class="panel-body" id="bootstrap-panel-body"> <div class="form-item webform-component webform-component-textfield webform-component--complaining-party--name form-group form-item form-item-submitted-complaining-party-name form-type-textfield form-group"> <label class="control-label" for="edit-submitted-complaining-party-name">Name <span class="form-required" title="This field is required.">*</span></label> <input required="required" class="form-control form-text required" type="text" id="edit-submitted-complaining-party-name" name="submitted[complaining_party][name]" value="" size="60" maxlength="50" /></div><div class="form-item webform-component webform-component-textfield webform-component--complaining-party--address form-group form-item form-item-submitted-complaining-party-address form-type-textfield form-group"> <label class="control-label" for="edit-submitted-complaining-party-address">Address <span class="form-required" title="This field is required.">*</span></label> <input required="required" class="form-control form-text required" type="text" id="edit-submitted-complaining-party-address" name="submitted[complaining_party][address]" value="" size="60" maxlength="50" /></div><div class="form-item webform-component webform-component-textfield webform-component--complaining-party--city form-group form-item form-item-submitted-complaining-party-city form-type-textfield form-group"> <label class="control-label" for="edit-submitted-complaining-party-city">City <span class="form-required" title="This field is required.">*</span></label> <input required="required" class="form-control form-text required" type="text" id="edit-submitted-complaining-party-city" name="submitted[complaining_party][city]" value="" size="60" maxlength="50" /></div><div class="form-item webform-component webform-component-select webform-component--complaining-party--state form-group form-item form-item-submitted-complaining-party-state form-type-select form-group"> <label class="control-label" for="edit-submitted-complaining-party-state">State <span class="form-required" title="This field is required.">*</span></label> <select required="required" class="form-control form-select required" id="edit-submitted-complaining-party-state" name="submitted[complaining_party][state]"><option value="AL">Alabama</option><option value="AK">Alaska</option><option value="AS">American Samoa</option><option value="AZ">Arizona</option><option value="AR">Arkansas</option><option value="CA">California</option><option value="CO">Colorado</option><option value="CT">Connecticut</option><option value="DE">Delaware</option><option value="DC">District of Columbia</option><option value="FL">Florida</option><option value="GA">Georgia</option><option value="GU">Guam</option><option value="HI">Hawaii</option><option value="ID">Idaho</option><option value="IL">Illinois</option><option value="IN">Indiana</option><option value="IA">Iowa</option><option value="KS">Kansas</option><option value="KY">Kentucky</option><option value="LA">Louisiana</option><option value="ME">Maine</option><option value="MH">Marshall Islands</option><option value="MD">Maryland</option><option value="MA">Massachusetts</option><option value="MI">Michigan</option><option value="MN">Minnesota</option><option value="MS">Mississippi</option><option value="MO">Missouri</option><option value="MT">Montana</option><option value="NE">Nebraska</option><option value="NV">Nevada</option><option value="NH">New Hampshire</option><option value="NJ">New Jersey</option><option value="NM">New Mexico</option><option value="NY">New York</option><option value="NC">North Carolina</option><option value="ND">North Dakota</option><option value="MP">Northern Marianas Islands</option><option value="OH">Ohio</option><option value="OK">Oklahoma</option><option value="OR">Oregon</option><option value="PW">Palau</option><option value="PA">Pennsylvania</option><option value="PR">Puerto Rico</option><option value="RI">Rhode Island</option><option value="SC">South Carolina</option><option value="SD">South Dakota</option><option value="TN">Tennessee</option><option value="TX">Texas</option><option value="UT">Utah</option><option value="VT">Vermont</option><option value="VI">Virgin Islands</option><option value="VA">Virginia</option><option value="WA">Washington</option><option value="WV">West Virginia</option><option value="WI">Wisconsin</option><option value="WY">Wyoming</option></select></div><div class="form-item webform-component webform-component-textfield webform-component--complaining-party--zip form-group form-item form-item-submitted-complaining-party-zip form-type-textfield form-group"> <label class="control-label" for="edit-submitted-complaining-party-zip">Zip <span class="form-required" title="This field is required.">*</span></label> <input required="required" class="form-control form-text required" type="text" id="edit-submitted-complaining-party-zip" name="submitted[complaining_party][zip]" value="" size="60" maxlength="10" /></div><div class="form-item webform-component webform-component-textfield webform-component--complaining-party--home-phone-number form-group form-item form-item-submitted-complaining-party-home-phone-number form-type-textfield form-group"> <label class="control-label" for="edit-submitted-complaining-party-home-phone-number">Home Phone Number <span class="form-required" title="This field is required.">*</span></label> <input required="required" class="form-control form-text required" type="text" id="edit-submitted-complaining-party-home-phone-number" name="submitted[complaining_party][home_phone_number]" value="" size="60" maxlength="20" /></div><div class="form-item webform-component webform-component-textfield webform-component--complaining-party--work-phone-number form-group form-item form-item-submitted-complaining-party-work-phone-number form-type-textfield form-group"> <label class="control-label" for="edit-submitted-complaining-party-work-phone-number">Work Phone Number <span class="form-required" title="This field is required.">*</span></label> <input required="required" class="form-control form-text required" type="text" id="edit-submitted-complaining-party-work-phone-number" name="submitted[complaining_party][work_phone_number]" value="" size="60" maxlength="20" /></div><div class="form-item webform-component webform-component-email webform-component--complaining-party--email-address form-group form-item form-item-submitted-complaining-party-email-address form-type-webform-email form-group"> <label class="control-label" for="edit-submitted-complaining-party-email-address">Email Address <span class="form-required" title="This field is required.">*</span></label> <input required="required" class="email form-control form-text form-email required" type="email" id="edit-submitted-complaining-party-email-address" name="submitted[complaining_party][email_address]" size="60" /></div><div class="form-item webform-component webform-component-radios webform-component--complaining-party--preferred-method-of-contact form-group form-item form-item-submitted-complaining-party-preferred-method-of-contact form-type-radios form-group"> <label class="control-label" for="edit-submitted-complaining-party-preferred-method-of-contact">Preferred Method of Contact <span class="form-required" title="This field is required.">*</span></label> <div id="edit-submitted-complaining-party-preferred-method-of-contact" class="form-radios"><div class="form-item form-item-submitted-complaining-party-preferred-method-of-contact form-type-radio radio"> <label class="control-label" for="edit-submitted-complaining-party-preferred-method-of-contact-1"><input required="required" type="radio" id="edit-submitted-complaining-party-preferred-method-of-contact-1" name="submitted[complaining_party][preferred_method_of_contact]" value="home" class="form-radio" />Home</label> </div><div class="form-item form-item-submitted-complaining-party-preferred-method-of-contact form-type-radio radio"> <label class="control-label" for="edit-submitted-complaining-party-preferred-method-of-contact-2"><input required="required" type="radio" id="edit-submitted-complaining-party-preferred-method-of-contact-2" name="submitted[complaining_party][preferred_method_of_contact]" value="work" class="form-radio" />Work</label> </div><div class="form-item form-item-submitted-complaining-party-preferred-method-of-contact form-type-radio radio"> <label class="control-label" for="edit-submitted-complaining-party-preferred-method-of-contact-3"><input required="required" type="radio" id="edit-submitted-complaining-party-preferred-method-of-contact-3" name="submitted[complaining_party][preferred_method_of_contact]" value="email" class="form-radio" />Email</label> </div></div></div> </div> </fieldset> <fieldset class="webform-component-fieldset webform-component--complaint-aganist panel panel-default form-wrapper" id="bootstrap-panel--2"> <legend class="panel-heading"> <span class="panel-title fieldset-legend">Complaint Against</span> </legend> <div class="panel-body" id="bootstrap-panel-2-body"> <div class="form-item webform-component webform-component-textfield webform-component--complaint-aganist--company-name form-group form-item form-item-submitted-complaint-aganist-company-name form-type-textfield form-group"> <label class="control-label" for="edit-submitted-complaint-aganist-company-name">Company Name <span class="form-required" title="This field is required.">*</span></label> <input required="required" class="form-control form-text required" type="text" id="edit-submitted-complaint-aganist-company-name" name="submitted[complaint_aganist][company_name]" value="" size="60" maxlength="50" /></div><div class="form-item webform-component webform-component-textfield webform-component--complaint-aganist--company-address form-group form-item form-item-submitted-complaint-aganist-company-address form-type-textfield form-group"> <label class="control-label" for="edit-submitted-complaint-aganist-company-address">Company Address <span class="form-required" title="This field is required.">*</span></label> <input required="required" class="form-control form-text required" type="text" id="edit-submitted-complaint-aganist-company-address" name="submitted[complaint_aganist][company_address]" value="" size="60" maxlength="50" /></div><div class="form-item webform-component webform-component-textfield webform-component--complaint-aganist--company-city form-group form-item form-item-submitted-complaint-aganist-company-city form-type-textfield form-group"> <label class="control-label" for="edit-submitted-complaint-aganist-company-city">Company City <span class="form-required" title="This field is required.">*</span></label> <input required="required" class="form-control form-text required" type="text" id="edit-submitted-complaint-aganist-company-city" name="submitted[complaint_aganist][company_city]" value="" size="60" maxlength="50" /></div><div class="form-item webform-component webform-component-select webform-component--complaint-aganist--company-state form-group form-item form-item-submitted-complaint-aganist-company-state form-type-select form-group"> <label class="control-label" for="edit-submitted-complaint-aganist-company-state">Company State <span class="form-required" title="This field is required.">*</span></label> <select required="required" class="form-control form-select required" id="edit-submitted-complaint-aganist-company-state" name="submitted[complaint_aganist][company_state]"><option value="AL">Alabama</option><option value="AK">Alaska</option><option value="AS">American Samoa</option><option value="AZ">Arizona</option><option value="AR">Arkansas</option><option value="CA">California</option><option value="CO">Colorado</option><option value="CT">Connecticut</option><option value="DE">Delaware</option><option value="DC">District of Columbia</option><option value="FL">Florida</option><option value="GA">Georgia</option><option value="GU">Guam</option><option value="HI">Hawaii</option><option value="ID">Idaho</option><option value="IL">Illinois</option><option value="IN">Indiana</option><option value="IA">Iowa</option><option value="KS">Kansas</option><option value="KY">Kentucky</option><option value="LA">Louisiana</option><option value="ME">Maine</option><option value="MH">Marshall Islands</option><option value="MD">Maryland</option><option value="MA">Massachusetts</option><option value="MI">Michigan</option><option value="MN">Minnesota</option><option value="MS">Mississippi</option><option value="MO">Missouri</option><option value="MT">Montana</option><option value="NE">Nebraska</option><option value="NV">Nevada</option><option value="NH">New Hampshire</option><option value="NJ">New Jersey</option><option value="NM">New Mexico</option><option value="NY">New York</option><option value="NC">North Carolina</option><option value="ND">North Dakota</option><option value="MP">Northern Marianas Islands</option><option value="OH">Ohio</option><option value="OK">Oklahoma</option><option value="OR">Oregon</option><option value="PW">Palau</option><option value="PA">Pennsylvania</option><option value="PR">Puerto Rico</option><option value="RI">Rhode Island</option><option value="SC">South Carolina</option><option value="SD">South Dakota</option><option value="TN">Tennessee</option><option value="TX">Texas</option><option value="UT">Utah</option><option value="VT">Vermont</option><option value="VI">Virgin Islands</option><option value="VA">Virginia</option><option value="WA">Washington</option><option value="WV">West Virginia</option><option value="WI">Wisconsin</option><option value="WY">Wyoming</option></select></div><div class="form-item webform-component webform-component-textfield webform-component--complaint-aganist--company-zip form-group form-item form-item-submitted-complaint-aganist-company-zip form-type-textfield form-group"> <label class="control-label" for="edit-submitted-complaint-aganist-company-zip">Company Zip <span class="form-required" title="This field is required.">*</span></label> <input required="required" class="form-control form-text required" type="text" id="edit-submitted-complaint-aganist-company-zip" name="submitted[complaint_aganist][company_zip]" value="" size="60" maxlength="10" /></div><div class="form-item webform-component webform-component-radios webform-component--complaint-aganist--have-you-contacted-your-local-law-enforcement-agency form-group form-item form-item-submitted-complaint-aganist-have-you-contacted-your-local-law-enforcement-agency form-type-radios form-group"> <label class="control-label" for="edit-submitted-complaint-aganist-have-you-contacted-your-local-law-enforcement-agency">Have you contacted your local law enforcement agency? </label> <div id="edit-submitted-complaint-aganist-have-you-contacted-your-local-law-enforcement-agency" class="form-radios"><div class="form-item form-item-submitted-complaint-aganist-have-you-contacted-your-local-law-enforcement-agency form-type-radio radio"> <label class="control-label" for="edit-submitted-complaint-aganist-have-you-contacted-your-local-law-enforcement-agency-1"><input type="radio" id="edit-submitted-complaint-aganist-have-you-contacted-your-local-law-enforcement-agency-1" name="submitted[complaint_aganist][have_you_contacted_your_local_law_enforcement_agency]" value="no" class="form-radio" />No</label> </div><div class="form-item form-item-submitted-complaint-aganist-have-you-contacted-your-local-law-enforcement-agency form-type-radio radio"> <label class="control-label" for="edit-submitted-complaint-aganist-have-you-contacted-your-local-law-enforcement-agency-2"><input type="radio" id="edit-submitted-complaint-aganist-have-you-contacted-your-local-law-enforcement-agency-2" name="submitted[complaint_aganist][have_you_contacted_your_local_law_enforcement_agency]" value="yes" class="form-radio" />Yes</label> </div></div></div><div class="form-item webform-component webform-component-textfield webform-component--complaint-aganist--if-yes-name-of-agency form-group form-item form-item-submitted-complaint-aganist-if-yes-name-of-agency form-type-textfield form-group"> <label class="control-label" for="edit-submitted-complaint-aganist-if-yes-name-of-agency">If yes, name of agency</label> <input class="form-control form-text" type="text" id="edit-submitted-complaint-aganist-if-yes-name-of-agency" name="submitted[complaint_aganist][if_yes_name_of_agency]" value="" size="60" maxlength="50" /></div><div class="form-item webform-component webform-component-radios webform-component--complaint-aganist--have-you-contacted-another-state-agency form-group form-item form-item-submitted-complaint-aganist-have-you-contacted-another-state-agency form-type-radios form-group"> <label class="control-label" for="edit-submitted-complaint-aganist-have-you-contacted-another-state-agency">Have you contacted another state agency?</label> <div id="edit-submitted-complaint-aganist-have-you-contacted-another-state-agency" class="form-radios"><div class="form-item form-item-submitted-complaint-aganist-have-you-contacted-another-state-agency form-type-radio radio"> <label class="control-label" for="edit-submitted-complaint-aganist-have-you-contacted-another-state-agency-1"><input type="radio" id="edit-submitted-complaint-aganist-have-you-contacted-another-state-agency-1" name="submitted[complaint_aganist][have_you_contacted_another_state_agency]" value="no" class="form-radio" />No</label> </div><div class="form-item form-item-submitted-complaint-aganist-have-you-contacted-another-state-agency form-type-radio radio"> <label class="control-label" for="edit-submitted-complaint-aganist-have-you-contacted-another-state-agency-2"><input type="radio" id="edit-submitted-complaint-aganist-have-you-contacted-another-state-agency-2" name="submitted[complaint_aganist][have_you_contacted_another_state_agency]" value="yes" class="form-radio" />Yes</label> </div></div></div><div class="form-item webform-component webform-component-textfield webform-component--complaint-aganist--if-yes-name-of-state-agency form-group form-item form-item-submitted-complaint-aganist-if-yes-name-of-state-agency form-type-textfield form-group"> <label class="control-label" for="edit-submitted-complaint-aganist-if-yes-name-of-state-agency">If yes, name of state agency</label> <input class="form-control form-text" type="text" id="edit-submitted-complaint-aganist-if-yes-name-of-state-agency" name="submitted[complaint_aganist][if_yes_name_of_state_agency]" value="" size="60" maxlength="50" /></div><div class="form-item webform-component webform-component-radios webform-component--complaint-aganist--have-you-contacted-an-attorney form-group form-item form-item-submitted-complaint-aganist-have-you-contacted-an-attorney form-type-radios form-group"> <label class="control-label" for="edit-submitted-complaint-aganist-have-you-contacted-an-attorney">Have you contacted an attorney?</label> <div id="edit-submitted-complaint-aganist-have-you-contacted-an-attorney" class="form-radios"><div class="form-item form-item-submitted-complaint-aganist-have-you-contacted-an-attorney form-type-radio radio"> <label class="control-label" for="edit-submitted-complaint-aganist-have-you-contacted-an-attorney-1"><input type="radio" id="edit-submitted-complaint-aganist-have-you-contacted-an-attorney-1" name="submitted[complaint_aganist][have_you_contacted_an_attorney]" value="no" class="form-radio" />No</label> </div><div class="form-item form-item-submitted-complaint-aganist-have-you-contacted-an-attorney form-type-radio radio"> <label class="control-label" for="edit-submitted-complaint-aganist-have-you-contacted-an-attorney-2"><input type="radio" id="edit-submitted-complaint-aganist-have-you-contacted-an-attorney-2" name="submitted[complaint_aganist][have_you_contacted_an_attorney]" value="yes" class="form-radio" />Yes</label> </div></div></div><div class="form-item webform-component webform-component-textfield webform-component--complaint-aganist--if-yes-name-of-attorney form-group form-item form-item-submitted-complaint-aganist-if-yes-name-of-attorney form-type-textfield form-group"> <label class="control-label" for="edit-submitted-complaint-aganist-if-yes-name-of-attorney">If yes, name of attorney</label> <input class="form-control form-text" type="text" id="edit-submitted-complaint-aganist-if-yes-name-of-attorney" name="submitted[complaint_aganist][if_yes_name_of_attorney]" value="" size="60" maxlength="50" /></div><div class="form-item webform-component webform-component-radios webform-component--complaint-aganist--is-there-a-court-action-pending form-group form-item form-item-submitted-complaint-aganist-is-there-a-court-action-pending form-type-radios form-group"> <label class="control-label" for="edit-submitted-complaint-aganist-is-there-a-court-action-pending">Is there a court action pending?</label> <div id="edit-submitted-complaint-aganist-is-there-a-court-action-pending" class="form-radios"><div class="form-item form-item-submitted-complaint-aganist-is-there-a-court-action-pending form-type-radio radio"> <label class="control-label" for="edit-submitted-complaint-aganist-is-there-a-court-action-pending-1"><input type="radio" id="edit-submitted-complaint-aganist-is-there-a-court-action-pending-1" name="submitted[complaint_aganist][is_there_a_court_action_pending]" value="no" class="form-radio" />No</label> </div><div class="form-item form-item-submitted-complaint-aganist-is-there-a-court-action-pending form-type-radio radio"> <label class="control-label" for="edit-submitted-complaint-aganist-is-there-a-court-action-pending-2"><input type="radio" id="edit-submitted-complaint-aganist-is-there-a-court-action-pending-2" name="submitted[complaint_aganist][is_there_a_court_action_pending]" value="yes" class="form-radio" />Yes</label> </div></div></div><div class="form-item webform-component webform-component-textfield webform-component--complaint-aganist--if-yes-name-of-court form-group form-item form-item-submitted-complaint-aganist-if-yes-name-of-court form-type-textfield form-group"> <label class="control-label" for="edit-submitted-complaint-aganist-if-yes-name-of-court">If yes, name of court</label> <input class="form-control form-text" type="text" id="edit-submitted-complaint-aganist-if-yes-name-of-court" name="submitted[complaint_aganist][if_yes_name_of_court]" value="" size="60" maxlength="50" /></div><div class="form-item webform-component webform-component-radios webform-component--complaint-aganist--have-you-lost-a-lawsuit-in-this-matter form-group form-item form-item-submitted-complaint-aganist-have-you-lost-a-lawsuit-in-this-matter form-type-radios form-group"> <label class="control-label" for="edit-submitted-complaint-aganist-have-you-lost-a-lawsuit-in-this-matter">Have you lost a lawsuit in this matter?</label> <div id="edit-submitted-complaint-aganist-have-you-lost-a-lawsuit-in-this-matter" class="form-radios"><div class="form-item form-item-submitted-complaint-aganist-have-you-lost-a-lawsuit-in-this-matter form-type-radio radio"> <label class="control-label" for="edit-submitted-complaint-aganist-have-you-lost-a-lawsuit-in-this-matter-1"><input type="radio" id="edit-submitted-complaint-aganist-have-you-lost-a-lawsuit-in-this-matter-1" name="submitted[complaint_aganist][have_you_lost_a_lawsuit_in_this_matter]" value="no" class="form-radio" />No</label> </div><div class="form-item form-item-submitted-complaint-aganist-have-you-lost-a-lawsuit-in-this-matter form-type-radio radio"> <label class="control-label" for="edit-submitted-complaint-aganist-have-you-lost-a-lawsuit-in-this-matter-2"><input type="radio" id="edit-submitted-complaint-aganist-have-you-lost-a-lawsuit-in-this-matter-2" name="submitted[complaint_aganist][have_you_lost_a_lawsuit_in_this_matter]" value="yes" class="form-radio" />Yes</label> </div></div></div><div class="form-item webform-component webform-component-textarea webform-component--complaint-aganist--please-provide-a-factual-statement-that-clearly-describes-the-date-place-and-nature-of-the-incident-or-issue-that-you-are-report form-group form-item form-item-submitted-complaint-aganist-please-provide-a-factual-statement-that-clearly-describes-the-date-place-and-nature-of-the-incident-or-issue-that-you-are-report form-type-textarea form-group"> <label class="control-label" for="edit-submitted-complaint-aganist-please-provide-a-factual-statement-that-clearly-describes-the-date-place-and-nature-of-the-incident-or-issue-that-you-are-report">Please provide a factual statement that clearly describes the date, place and nature of the incident or issue that you are reporting. <span class="form-required" title="This field is required.">*</span></label> <div class="form-textarea-wrapper resizable"><textarea required="required" class="form-control form-textarea required" id="edit-submitted-complaint-aganist-please-provide-a-factual-statement-that-clearly-describes-the-date-place-and-nature-of-the-incident-or-issue-that-you-are-report" name="submitted[complaint_aganist][please_provide_a_factual_statement_that_clearly_describes_the_date_place_and_nature_of_the_incident_or_issue_that_you_are_report]" cols="60" rows="5"></textarea></div></div><div class="form-item webform-component webform-component-textarea webform-component--complaint-aganist--briefly-describe-how-you-believe-this-office-can-be-of-assistance form-group form-item form-item-submitted-complaint-aganist-briefly-describe-how-you-believe-this-office-can-be-of-assistance form-type-textarea form-group"> <label class="control-label" for="edit-submitted-complaint-aganist-briefly-describe-how-you-believe-this-office-can-be-of-assistance">Briefly describe how you believe this office can be of assistance.</label> <div class="form-textarea-wrapper resizable"><textarea class="form-control form-textarea" id="edit-submitted-complaint-aganist-briefly-describe-how-you-believe-this-office-can-be-of-assistance" name="submitted[complaint_aganist][briefly_describe_how_you_believe_this_office_can_be_of_assistance]" cols="60" rows="5"></textarea></div></div><div class="form-item webform-component webform-component-radios webform-component--complaint-aganist--i-will-sign-a-sworn-statement-if-requested form-group form-item form-item-submitted-complaint-aganist-i-will-sign-a-sworn-statement-if-requested form-type-radios form-group"> <label class="control-label" for="edit-submitted-complaint-aganist-i-will-sign-a-sworn-statement-if-requested">I will sign a sworn statement if requested.</label> <div id="edit-submitted-complaint-aganist-i-will-sign-a-sworn-statement-if-requested" class="form-radios"><div class="form-item form-item-submitted-complaint-aganist-i-will-sign-a-sworn-statement-if-requested form-type-radio radio"> <label class="control-label" for="edit-submitted-complaint-aganist-i-will-sign-a-sworn-statement-if-requested-1"><input type="radio" id="edit-submitted-complaint-aganist-i-will-sign-a-sworn-statement-if-requested-1" name="submitted[complaint_aganist][i_will_sign_a_sworn_statement_if_requested]" value="yes" class="form-radio" />Yes</label> </div><div class="form-item form-item-submitted-complaint-aganist-i-will-sign-a-sworn-statement-if-requested form-type-radio radio"> <label class="control-label" for="edit-submitted-complaint-aganist-i-will-sign-a-sworn-statement-if-requested-2"><input type="radio" id="edit-submitted-complaint-aganist-i-will-sign-a-sworn-statement-if-requested-2" name="submitted[complaint_aganist][i_will_sign_a_sworn_statement_if_requested]" value="no" class="form-radio" />No</label> </div></div></div><div class="form-item webform-component webform-component-radios webform-component--complaint-aganist--by-submitting-this-form-i-certify-that-i-understand-that-the-attorney-general-does-not-represent-private-citizens-seeking-the-re form-group form-item form-item-submitted-complaint-aganist-by-submitting-this-form-i-certify-that-i-understand-that-the-attorney-general-does-not-represent-private-citizens-seeking-the-re form-type-radios form-group"> <label class="control-label" for="edit-submitted-complaint-aganist-by-submitting-this-form-i-certify-that-i-understand-that-the-attorney-general-does-not-represent-private-citizens-seeking-the-re">By submitting this form, I certify that I understand that the Attorney General does not represent private citizens seeking the return of money or other personal remedies.</label> <div id="edit-submitted-complaint-aganist-by-submitting-this-form-i-certify-that-i-understand-that-the-attorney-general-does-not-represent-private-citizens-seeking-the-re" class="form-radios"><div class="form-item form-item-submitted-complaint-aganist-by-submitting-this-form-i-certify-that-i-understand-that-the-attorney-general-does-not-represent-private-citizens-seeking-the-re form-type-radio radio"> <label class="control-label" for="edit-submitted-complaint-aganist-by-submitting-this-form-i-certify-that-i-understand-that-the-attorney-general-does-not-represent-private-citizens-seeking-the-re-1"><input type="radio" id="edit-submitted-complaint-aganist-by-submitting-this-form-i-certify-that-i-understand-that-the-attorney-general-does-not-represent-private-citizens-seeking-the-re-1" name="submitted[complaint_aganist][by_submitting_this_form_i_certify_that_i_understand_that_the_attorney_general_does_not_represent_private_citizens_seeking_the_re]" value="yes" class="form-radio" />Yes</label> </div><div class="form-item form-item-submitted-complaint-aganist-by-submitting-this-form-i-certify-that-i-understand-that-the-attorney-general-does-not-represent-private-citizens-seeking-the-re form-type-radio radio"> <label class="control-label" for="edit-submitted-complaint-aganist-by-submitting-this-form-i-certify-that-i-understand-that-the-attorney-general-does-not-represent-private-citizens-seeking-the-re-2"><input type="radio" id="edit-submitted-complaint-aganist-by-submitting-this-form-i-certify-that-i-understand-that-the-attorney-general-does-not-represent-private-citizens-seeking-the-re-2" name="submitted[complaint_aganist][by_submitting_this_form_i_certify_that_i_understand_that_the_attorney_general_does_not_represent_private_citizens_seeking_the_re]" value="no" class="form-radio" />No</label> </div></div></div> </div> </fieldset> <input type="hidden" name="details[sid]" /> <input type="hidden" name="details[page_num]" value="1" /> <input type="hidden" name="details[page_count]" value="1" /> <input type="hidden" name="details[finished]" value="0" /> <input type="hidden" name="form_build_id" value="form-_u-vGEkLS4z109BRVH8TI3sWkP0Pro9dn2wOSyrlK4s" /> <input type="hidden" 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