Forms • West Haven Board of Ethics Complaint Form

West Haven Board of Ethics Complaint Form

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City of West Haven Board of Ethics Complaint Form

- Your name and contact information will remain confidential. Please fill in at least one
of the contact fields below so a member of the Board of Ethics can contact you for
further information, if necessary, and to update you on the outcome of the case.

- Complaints, including any exhibits, may be submitted electronically, or addressed to
the board and marked “Ethics Complaint-Confidential.” A sealed envelope shall be
delivered to the City Clerk either by hand or by certified mail, return receipt
requested. The complaint shall be deemed to have been filed on the date of its receipt
by the City Clerk and the City Clerk shall treat the complaint as a confidential
document. The City Clerk shall issue a dated, signed receipt to the complainant, upon
request.

-The City Clerk shall not open the sealed envelope but shall notify the chair within 24
hours after receipt and arrange for its prompt delivery to the chair.

Section I : Complainant Information

Name*

Street Address*

City*

State

Zip Code*

Phone Number

Email Address

If additional People Need to be listed please list here

Section II : Complaint Information

Please provide all available information about the
person(s) or entity(s) you believe potentially may have been involved in an ethics violation.

This person or entity is a*

If "Other", please explain in the provided field.

Person's or Entity's Name

Person's Position with City (if applicable):

Name and Address of Person/Business/Organization:

Email address

Phone Number:

Section III : Details of the incident (s)

The more details you provide, the better we may
investigate your complaint. Please provide a full description of the circumstances that
prompted your complaint. Attach supporting documentation, as appropriate, including
letters, e-mails, photographs, video or audio tapes, etc…

Date Of Incident:

Approximate Time of Incident:

Location(s) of Incident:

Narrative/ Description of Event:

Section IV: Witness Information

Name

Street Address:

City:

State:

Zip Code

Phone Number:

Email Address:

If additional people need to be listed, please use this space to list additional witnesses.
Please Include all additional witnesses': Names, Street Addresses, City, State, Zip Code, Phone Number, and Email.

Section V: Video Or Audio Evidence

Any supporting videos or audio files should accompany the hard copy compalint.

Section VI: Miscellaneous

Are you able to read, write and speak the English language? *

Yes

Section VII: Affirmation of Statement

Please type your name in the space below to electronically sign your Online Ethics
Complaint Form and acknowledge CGS 53a-157b – False Statement:
Sec. 53a-157b. False statement: Class A misdemeanor. (a) A person is guilty of false
statement when such person (1) intentionally makes a false written statement that such person
does not believe to be true with the intent to mislead a public servant in the performance of such
public servant’s official function, and (2) makes such statement under oath or pursuant to a form
bearing notice, authorized by law, to the effect that false statements made therein are punishable.
I SOLEMNLY AFFIRM UNDER PENALTIES OF PERJURY and CGS 53a-157b -FALSE
STATEMENT - THE CONTENTS OF THIS COMPLAINT FORM AND OF ANY
ACCOMPANYING INFORMATION ARE TRUE TO THE BEST OF MY KNOWLEDGE,
INFORMATION, AND BELIEF

Todays Date:

Signature Affirmation:*

I hereby acknowledge that my actual signature and/or typed name above (for online complaint)
shall serve as my sworn affirmation that my complaint is truthful to the best of my knowledge

* indicates required fields.

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