WIA Title I-B Program Complaint Form
1. Complainant Information
State your name and address (include: city, state, zip code)
Area Code / Number Area Code / Number
2. Agency Information
Provide name and address of agency involved
Telephone Number of Respondent
Area Code / Number
3. What is the most convenient time and place for us to contact you about this complaint?
4. To your best recollection on what date(s) did the alleged issue take place?
Date of first occurrence Date of most recent occurrence
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Explain as briefly and clearly as possible the issue (reason for) of the complaint and a brief
written statement of the allegations. If other persons were treated differently from you,
include information as to how they were treated differently than you. Also attach any written
material pertaining to your case.
Please list below any persons (witnesses, fellow employees, supervisors, or others) that we
may contact for additional information to support or clarify your complaint.
Name Relationship Address Number
Signed (Program Complaint Not Valid unless signed*) Date
*If you need assistance, please ask a staff member.
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