Fillable CRIME VICTIM JUSTICE UNIT COMPLAINT FORM (Minnesota)

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CRIME VICTIM JUSTICE UNIT COMPLAINT FORM (Minnesota)

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Crime Victim Justice Unit Complaint Form, Revised 3-19 Page 1 of 4
CRIME VICTIM JUSTICE UNIT COMPLAINT FORM
The Crime Victim Justice Unit (CVJU) is located within the Minnesota Department of Public Safety
Office of Justice Programs. The CVJU has the legal authority under Minnesota Statutes section 611A.74
to investigate complaints from crime victims about actions by members of the criminal justice system
and victim service organizations, except the judiciary.
Instructions:
• Complete all sections of the form and sign the last page.
• Include copies of any relevant documents. Do not send originals.
• For questions, please contact the CVJU: 651-201-7310 or cvju.ojp@state.mn.us.
• Return the form by faxing, emailing, or mailing to:
Crime Victim Justice Unit
Minnesota Office of Justice Programs
445 Minnesota Street, Suite 2300
St. Paul, MN 55101-1515
Fax: 651-296-5787 | cvju.ojp@state.mn.us
YOUR INFORMATION
Your name: Date of birth (month/day/year): Gender:
Your mailing address (including apartment number): City: State: Zip code:
Email address Cell phone number: Day phone number:
Name and phone of person to contact if we are unable to reach
you regarding this complaint:
Prefer
red contact method during the day:
Cell phone Day phone Email
VICTIM INFORMATION (COMPLETE IF YOU ARE NOT THE VICTIM)
Victim’s name: Date of birth (month/day/year)
Date of death, if deceased (month/day/year): Gender: Your relationship to the victim:
Crime Victim Justice Unit Complaint Form, Revised 3-19 Page 2 of 4
INFORMATION ABOUT THE CRIME
Offender’s name
Offender’s date of birth
(month/day/year)
Date of the crime (month/day/year) City in which crime occurred: County in which crime occurred:
Name of law enforcement agency that took the report: Law enforcement case number (if known):
Relationship between the offender and the victim: Did you receive a victim information card or packet listing
your crime victim rights from the law enforcement agency?
INFORMATION ABOUT YOUR COMPLAINT
What agency or organization do you have a complaint against? If your complaint is about a specific
individual within an agency/organization, please name. You will be able to describe your complaint in
detail on the next page.
Agency/organization name
Person complained about
Please describe what steps, if any, you have already taken to resolve your complaint, such as
complaining to the agency or filing a formal complaint elsewhere.
Yes No
Don't recall
Crime Victim Justice Unit Complaint Form, Revised 3-19 Page 3 of 4
STATEMENT OF COMPLAINT
Please describe your complaint in detail.
Check here if you are attaching additional pages for your statement
Crime Victim Justice Unit Complaint Form, Revised 3-19 Page 4 of 4
TENNESSEN WARNING AND CONSENT TO INVESTIGATE
TENNESSEN WARNING
The CVJU has asked for the information you supplied in this form to be able to investigate your complaint. You are
not legally required to provide us with this information. Without providing this information, however, we cannot
proceed with an investigation.
To investigate your complaint, the CVJU investigator will contact any agency or organization you are complaining
about to request information about your case. The CVJU investigator may need to contact other agencies or
organizations that have information about the case or your complaint. In these contacts, the following
information will be revealed: (1) your name, (2) the fact that you filed a complaint with the CVJU, and (3) the
nature of your complaint. Information about your complaint will be disclosed only to the extent necessary to
conduct an investigation.
By signing this form, you are giving consent to the CVJU to disclose this information to any agency or organization
you are complaining about or those agencies or organizations that have information relevant to your case or
complaint.
CONSENT TO INVESTIGATION:
I understand that upon receipt of this form, the CVJU may conduct an investigation into matters relevant to this
complaint, and I hereby consent to such investigation. This authorization is valid until the CVJU investigation is
completed or three years from this date, whichever is sooner.
I certify that I have read and understand all of the statements above and that the information I have provided in
this CVJU complaint form is correct.
__________________________
___________________________ ______________
Date
PLEASE RETURN THIS FORM TO THE CRIME VICTIM JUSTICE UNIT BY ONE OF THESE METHODS:
• MAIL: Print, sign, and mail a copy to: CVJU, 445 Minnesota Street, Suite 2300, St. Paul, MN 55101-1515,
• FAX: Print, sign, and fax a copy to: 651-296-5787,
• SCAN/EMAIL: Print, sign, scan, and email a copy to: cvju.ojp@state.mn.us, or
• EMAIL/No signature: Type your name into the signature line, save this PDF as a separate file, and email the
file to cvju.ojp@state.mn.us. (If the CVJU opens an investigation, you will be asked to provide a signed copy of
this last page.)
Your complaint form will be reviewed and an investigator will contact you. Not all complaints will result in an
investigation. If you have questions, please contact the CVJU at 651-201-7310 or cvju.ojp@state.mn.us.
A NOTE ABOUT MINNESOTA DATA PRACTICES WITH RESPECT TO CVJU FILES
During the CVJU investigation, all information in the CVJU complaint file is considered confidential. After the investigation is
completed, the information in the complaint file is considered private data on individuals. If the CVJU receives confidential
information during its investigation, the information retains this classification even after the investigation is completed.
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CRIME VICTIM JUSTICE UNIT COMPLAINT FORM (Minnesota)

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Completed 30 January 2021

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