FOR OFFICE USE ONLY DATE RECEIVED: CASE NUMBER: COMPLAINT ALLEGING FAILURE OF DEPARTMENT OF JUSTICE EMPLOYEE TO PROVIDE RIGHTS TO A CRIME VICTIM UNDER THE CRIME VICTIMS' RIGHTS ACT OF 2004 Return the signed complaint, including any additional pages or documents, directly to the Department ofJustice component, or local United States Attorney's Office, that is named in your complaint Ifyou do not know where to send the complaint, you may send it directly to the Office of the Victims' Rights Ombudsman, who will forward your complaint to the office that is the subject of your complaint. Jennifer Hodge Criminal Division Office of Enforcement Operations 1301 New York Avenue, N.W. Washington, DC 20530 Fax: (202) 514.0163 This Complaint form is not designed for the correction of specific victims' rights violations, but is instead to request corrective or disciplinary action against Department of Justice employees who may have failed to provide or have violated the rights of a crime victim under the Crime Victims' Rights Act of 2004. A crime victim includes any person who has been directly and proximately harmed as a result of the commission of a Federal offense or an offense in the District of Columbia. All complaints must be submitted within sixty (60) days of the victim's knowledge of a violation by the Department of Justice employee, but not more than one year after the actual violation. Receipt of complaints will be acknowledged in writing. The information provided herein will be used along with other information developed during the investigation to resolve or otherwise determine the merits of this complaint. The information may be furnished to designated officers and employees of agencies and departments of the Federal Government in order to resolve or otherwise determine the merits of this complaint. Please check the box that applies to the person filing this complaint. O Victim X Attorney representing victim O Legal Guardian O