Date:
Name:
Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Email:
Include such things as: the date the alleged activity first occurred, whether the alleged behavior is still occurring, and whether you notified a supervisor or manager or any other State agency personnel or law enforcement about this allegation. (Additional pages may be attached, if necessary.)
If you have supporting material or documentation relevant to this complaint, please attach a copy to a completed copy of this form and mail or fax to:
Office of the State Comptroller Investigations Unit 110 State Street 14th Floor Albany, NY 12236 Toll-Free Phone: 1-888-672-4555 Fax: 518-408-3830