Complaint Form - Environmental Protection Page 2

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Have you ever reported the subject of your complaint to any other government agency? If yes, please:

A. Identify the governmental agency of agencies and the location to which you made your complaint:

B. The person or persons to whom you submitted the complaint, if known and that person’s or persons’ telephone number(s)

C. Each agency’s response to your complaint.

Please describe the complaint below.

Briefly describe your complaint:

Read the following before signing below.

NOTE: In order to resolve your complaint we may send a copy of this form to the individual

or company about whom you are complaining.

In filing this complaint, I understand that the Attorney General is not my private attorney, but represents the public and has specific powers by law to address certain

violations of environmental laws. I also understand that this complaint form is not a lawsuit. I agree that the Attorney General’s office may use its discretion to

determine whether an investigation is warranted, and may need to contact the person/entity I am complaining about. If I have any questions concerning my legal

rights or responsibilities, I should contact a private attorney. The above complaint is true and accurate to the best of my knowledge.

I also understand that any false statements made in this complaint are punishable as a Class A Misdemeanor under § 175.30 and/or § 210.34 of the Penal Law.

Signature

Date:

Remember to enclose COPIES of any documentation with regard to this complaint.

Return to: NYS Office of the Attorney General

Environmental Protection Bureau

The Capitol

Albany, NY 12224-0341

EPB001 - (rev. 12/14)