CVRA Complaint Form

FOR OFFICE USE ONLY
DATE RECEIVED: _____________
CASE NUMBER: _______________

COMPLAINT
ALLEGING FAILURE OF DEPARTMENT OF JUSTICE EMPLOYEE
TO PROVIDE RIGHTS TO A CRIME VICTIM UNDER
THE CRIME VICTIMS’ RIGHTS ACT OF 2004
Return the signed complaint, including any additional pages or
documents, directly to the Department of Justice component, or
local United States Attorney’s Office, that is named in your
complaint. If you do not know where to send the complaint, you
may send it directly to the Office of the Victims’ Rights
Ombudsman, who will forward your complaint to the office that
is the subject of your complaint.

Victims’ Rights Ombudsman
Executive Office for United States Attorneys
Department of Justice
2261 RFK Main Justice Building
950 Pennsylvania Ave., N.W .
W ashington, DC 20530-0001
Fax: (202) 252-1011

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.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB
control Number. Public reporting burden for this collection of information is estimated to average 45 minutes per response, including time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to
this collection is voluntary. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this
burden, to the U.S. Department of Justice, Executive Office for United States Attorneys, Legal Programs, 175 N St NE, Washington DC 20002 and reference the OMB
Control Number 1105-0NEW or the form title. Note: Please do not return the completed form to this address.

Please check the box that applies to the person filing this complaint.
G
G

Victim
Legal Guardian

G
G

Attorney representing victim
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?

G Yes

G 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.

Page 1 of 4
OMB Number: 1105-0NEW
Expiration Date: XX/XX/XXXX

1.

PERSONAL INFORM ATION ABOUT THE VICTIM

First Name:
Title:

Mr. ___

Middle Name:
Mrs. ___

Ms. ___

Last Name:

Miss ___

Other ___

Street Address:
City:

State:

Country:

Home Telephone No:

W ork Telephone No:

Zip Code:
Cell Phone No:

Email Address:

2.

INFORM ATION ABOUT THE CRIM INAL CASE
The following section requests important information about the criminal investigation or case in which you are a victim.
Please provide as much information as you can.

Stage of the Criminal Justice Process - Select most recent event:
G Investigation G Arrest G Arraignment G Preliminary Hearing
G Other ________________________________________

G Guilty Plea

G Trial G Sentencing

G Parole Hearing

Defendant(s) Name(s):
Case Number:

3.

District Court:

Judge:

INFORM ATION ABOUT THE VICTIM ’S COM PLAINT
W hat is the location and name of the office(s) or organization(s) of the Department of Justice that is/are the subject of your
complaint?

Is your complaint against a specific person in that office?

G Yes

G No

If yes, please identify the person(s) (include position or title, if known) who failed to provide the right(s) about which you are
complaining.

Page 2 of 4

Which of the following rights afforded by the Crime Victims’ Rights Act of 2004, 18 U.S.C. § 3771, do you feel you were
denied? Please check all that apply.
The right to be reasonably protected from the accused.
The right to reasonable, accurate, and timely notice of any public court proceeding, or any parole proceeding,
involving the crime or of any release or escape of the accused.
The right not to be excluded from any such public court proceeding, unless the court, after receiving clear and
convincing evidence, determines that testimony by the victim would be materially altered if the victim heard
other testimony at that proceeding.
The right to be reasonably heard at any public proceeding in the district court involving release, plea,
sentencing, or any parole proceeding.
The reasonable right to confer with the attorney for the Government in the case.
The right to full and timely restitution as provided by law.
The right to proceedings free from unreasonable delay.
The right to be treated with fairness and with respect for the victim’s dignity and privacy.
The right to be informed in a timely manner of any plea bargain or deferred prosecution agreement.
The right to be informed of the rights under this section and the services described in section 503(c) of the
Victims' Rights and Restitution Act of 1990 (42 U.S.C. 10607(c)) and provided contact information for the
Office of the Victims' Rights Ombudsman of the Department of Justice.

4.

STATEMENT OF COMPLAINANT
Please provide as much detailed information about your complaint against the Department of Justice employee(s) as
possible, including the date(s) of the alleged violation(s), and an explanation of how the violation(s) occurred. However,
you should not discuss the facts of the criminal investigation or case in which you are a victim. You may attach
additional pages or documents to this complaint.

Page 3 of 4

5.

PRIOR NOTIFICATION TO THE DEPARTM ENT OF JUSTICE
Although you are not required to do so, did you notify the Department of Justice employee, or any employee of the office
described above, of the alleged violation before filing this complaint?
G Yes
G No
If yes, please describe your efforts to resolve this matter, including the date(s) that you notified the Department of Justice
employee or any employee of the office described above; the name, address and telephone number of the person with whom
you attempted to resolve this matter; and the actions taken by the Department of Justice employee or office to resolve your
complaint. You may attached additional pages or documents to this complaint.

6.

OTHER RELEVANT INFORM ATION
Provide any other relevant information or event(s). You may attach additional pages or documents to this complaint.

The information set forth herein is true and correct to the best of my knowledge.
Signature:

________________________________________
(Must be signed by Victim)

Date: ____________________________

If the crime victim is under 18 years of age, incompetent, incapacitated, or deceased, this form must be signed by the Legal Guardian
of the crime victim or the representative of the crime victim’s estate, family member, or any other person appointed by the court.
Please check all that apply to the victim:
G Under 18 years of age
Signature:

G Incapacitated

G Incompetent

________________________________________

Page 4 of 4

G Deceased

Date: ____________________________

Rev. 0/