• WHAT TYPE OF CASE: FAMILY □ HOUSING □ CIVIL □ CRIMINAL □ SMALL CLAIMS □ APPELLATE □ SUPREME □

    DO YOU BELIEVE YOUR COURT FILES WERE TAMPERED WITH BY CLERKS/JUDGES? YES □ NO □

    IF MORE THAN ONE OFFICE FILL OUT SEPARATE APPLICATION FOR EACH COMPLAINT

    NAME: ___________________________________________________________________ DATE: ________________________
    ADDRESS: _______________________________________________________________________________________________

    PHONE:

    EMAIL: ______________________________________________

    WERE YOU ARRESTED?

    DATE YOU WERE ARRESTED: ____________ 

    DATE YOU WERE CONVICTED: ______________
    COURT LOCATION: ______________________________________________ JUDGE: _________________________________

    NAME OF PROSECUTOR:

    DID YOU HAVE AN ATTORNEY? __________

    NAME OF YOUR ATTORNEY:

    WAS THIS A PUBLIC DEFENDER?________

    WHAT WAS THE OUTCOME OF YOUR CASE: ____________

    _

    IF DCF CASE, WERE YOUR CHILD(REN) TAKEN AWAY? 

    HOW MANY CHILDREN? ________
    IF CHILD SUPPORT CASE, DID DSS AND ATTORNEY GENERAL’S OFFICE REPRESENT THE OTHER SIDE? ________
    WHERE DO YOU BELIEVE THE MISCONDUCT STARTED: POLICE _____ PROSECUTOR______ JUDGE________OTHER __________
    WHAT HAPPENED? WHY DO YOU BELIEVE THE STATE OF CONNECTICUT JUDICIAL SYSTEM MISTREATED YOU?
    __________________________________________________________________________________________________________
    __________________________________________________________________________________________________________
    __________________________________________________________________________________________________________
    __________________________________________________________________________________________________________
    DID YOU REPORT THE MISCONDUCT? ____________ IF SO, TO WHOM? ______________________________________
    WAS THE PERSON REPRIMANDED? __________ IF SO, HOW? _________________________________________________
    (Use additional sheet if necessary)
    DO YOU BELIEVE YOUR STATE AND/OR FEDERAL CONSTITUTIONAL RIGHTS WERE VIOLATED? YES □ NO □ DON’T KNOW □

    I attest under penalty of perjury that my statements are true to the best of my knowledge.

    ______________________________________
    Signature

    Mail to: The Attorney General of the United States, Dept. of Justice Rm. 4400, 950 Pennsylvania Ave. N.W,Washington, DC 20530-0001 - Fax no. 202-307-6777 Email: Askdoj@usdoj.gov 
    (Keep a copy for your records)