FOR OFFICE USE ONLY
DATE RECEIVED: _____________
CASE NUMBER: _______________
ALLEGING FAILURE OF DEPARTMENT OF JUSTICE EMPLOYEE TO PROVIDE RIGHTS
TO A CRIME VICTIM UNDER THE CRIME VICTIMS’ RIGHTS ACT OF 2004
Return signed form, including additional pages or documents, to:
ATF National Victim Witness Coordinator
Special Operations Branch
99 New York Ave., N.E.
Washington, D.C. 20226
Toll Free: 1-800-800-3855
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 of a crime victim under the Crime Victims’ Rights Act of 2004. A crime
victim includes any person who has been directly and proximately harmed as a result of the commission of
a Federal offense or an offense in the District of Columbia.
All complaints must be submitted within sixty (60) days of the victim’s knowledge of a violation by the
Department of Justice employee, but not more than one year after the actual violation. Receipt of
complaints will be acknowledged in writing.
The information provided herein will be used along with other information developed during the
investigation to resolve or otherwise determine the merits of this complaint. The information may be
furnished to designated officers and employees of agencies and departments of the Federal Government
in order to resolve or otherwise determine the merits of this complaint.
Please check the box that applies to the person filing this complaint.
Victim Attorney representing victim
Legal Guardian Other representative (describe) __________________________
Name, phone number and relationship to victim of person completing this form (if not the victim).
Is the victim represented by an attorney in this complaint? Yes No
If yes, please provide the attorney’s name and contact information. All future contacts with the victim
regarding this complaint will be made through the attorney.