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2. Complainant Name
4. First Name*
5. Last Name*
7. Complainant Address
9. Street Address*
10. Apartment, Suite, Etc.
12. City*
13. State*
14. Zip Code*
16. Phone Number*
17. Email Address*
19. Preferred Method of Contact*

    1. Phone

    1. Email

    1. Mail
21. Person or persons affected by the violation allegation, if different from Complainant.
23. First Name
24. Last Name
26. Street Address
27. Apartment, Suite, Etc.
29. City
30. State
31. Zip Code
33. Phone Number
34. Email Address
36. Location of Alleged Violation*
37. Date of Alleged Violation*
    Date of Alleged Violation
39. Additional Location/Date/Time Information
41. Description of Alleged Violation*
    Tell us your concern.
43. Remedy or Relief Requested*
    How can we fix your problem?
45. Has the complaint been filed with another bureau of the Department of Justice or any other Federal, State, or local civil rights agency or court?*

    1. Yes

    1. No
47. If the answer to the above question is yes, please provide a contact person and address below.
49. First Name
50. Last Name
52. Street Address
53. Apartment, Suite, Etc.
55. City
56. State
57. Zip Code
59. Phone Number
60. Email Address
62. Date Filed with Other Agency/Court
    Date Filed with Other Agency/Court
64. Signature*
65. Date*
    Date
67. If you have questions or issues with this form, please contact the City Clerk, Katie Nakazono at nakazonok@webstergroves.org or 314-963-5318.
69. If you are printing this form, please return to:
    City Clerk #4 E. Lockwood Webster Groves, MO 63119
Leave This Blank:


71. 1. Receive an email copy of this form.
72. Email address

    This field is not part of the form submission.

73. Submit Submit and Print

* indicates a required field