Delaware State
Fire Prevention Commission

Statement of Complaint Form

Person Making Complaint

Full Name

Address

Contact Number

Date

Do you wish to remain anonymous

Yes

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 Name, Address and Contact Number for complaint to be processed.

Your complaint is against

What is the Nname of the person/s or agency with Whom you are placing the complaint? (Or type “not sure”)

Name

Agency

What is your complaint? (Unlimited Characters – or you may cut and paste document).

Complaint

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