FOR OFFICE USE ONLY

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