Delaware State
Fire Prevention Commission

Statement of Complaint Form

Full Name

Address

Contact Number

Date

Do you wish to remain anonymous Yes No

Persons making a complaint may remain anonymous up until such time as the complaint comes to the Fire Prevention Commission for appropriate action.

Must fill in Your Name, Address and Contact Number for complaint to be processed.

Your complaint is against

Description of Complaint

Give detailed explanation. List date, time and location of complaint.

Incident Date

Incident Time

Incident Location

Name

Agency

Complaint

How would you prefer to be contacted?

What would you consider to be a fair resolution?

Do you wish to receive an email confirmation with case number? Yes No

Supporting Documentation and Evidence

Upload supporting documentation and evidence by uploading the files.
For video or large files, include a direct web link (URL) for multiple files or images.

Upload a document, photo or other evidence supporting your claim

Additional supporting document or photo

Link to Video or Photo Evidence

Disclosure

By submitting this complaint, you hereby certify under penalty of perjury that all information providing in your statements are true and correct to the best of my knowledge and you understand that any falsification of facts may result in criminal prosecution.

Disclosure Certification By checking this box I certify my statements are true and correct. (Required)

Sign your name electronically

Description of Complaint

Supporting Documentation and Evidence

Disclosure

Delaware's Government