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City of Farmington
Community Relations Commission
P.O. Box 192, Farmington, NM 87499
Message Center: 599-8442

COMPLAINT FORM
Name
 Phone
Address

 City
State
 Zip E-Mail
If needed, name of person who knows where to contact you:
Phone
 Address
Name of person, agency or institution you are filing a complaint against
Address
 City
State
 Zip
 Phone
 Is this address within the Farmington City limits ? Yes No
Date Problem Occurred
 Date(s) You Complained to Person/Agency
To Whom
 Name of Employee at Agency/ Institution this complaint is against
Have you filed a complaint with any other organization, court or governmental organization?
(check one ) Yes No If yes, please provide the information below.
Name
 Date Complaint Filed
Status of Complaint
What remedy are you seeking?
Signature Date
I swear or affirm the attached complaint is true to the best of my knowledge and information.



Witness Information (If any)

Name
 Phone
Address
 City
State
 Zip
 E-Mail

Name
 Phone
Address
 City
State
 Zip
 E-Mail

Name Phone
Address City
State Zip E-Mail

Name
 Phone
Address
 City
State
 Zip
 E-Mail

City of Farmington
Community Relations Commission

Write in chronological order the events that took place, and what steps you have taken so far.  If you need additional room, please use the back of this form or attach additional pages.  Include the name of the organization’s representative that you have been dealing with.  Please provide information and witnesses that are relevant to the situation, and attach copies of any paperwork you may have.  If you have witnesses, please provide their information on the next page.  Please keep a copy of this complaint for your records.
NOTE: This form and its contents, upon submission to the Commission, shall become a public record subject to disclosure to members of the public upon request as provided in the New Mexico Inspection of Public Records Act (NMSA Sections 14-2-1 through 14-2-12).