Michigan Attorney General Environmental Incident Report Form


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ENVIRONMENTAL INCIDENT REPORT FORM


(Only New Complaints May Be Filed On-Line) Please be aware of the following: When your complaint has been submitted, you will be informed of your Web Complaint Number in your confirmation. Please make an accurate record of this number. Complaints and inquiries become public records when they are submitted to the Attorney General's office, and under the Michigan Freedom of Information Act, copies may be subject to disclosure to anyone who asks for them. A copy of the complaint may be sent to other governmental agencies. Please be particularly cautious with information containing your Social Security number, credit card account numbers, etc. for security purposes. If you believe it is necessary to submit such information, you should mail that information and the corresponding complaint instead of sending it electronically. Do not use punctuation when providing names and addresses. NOTE: Fields labelled in RED are required values.
Complainant Information

	Check if you prefer to submit this complaint anonymously (form will reload)
Your Last Name:	* *	First Name:	* *	M.I.: *
Your Street Address:	* *	City:	* *
Your State:	*	Zip Code:	* *
Your County:		Your Home Phone:	*
E-mail Address:	* *	Your Work Phone:	*	* Ext:
Retype your E-mail:	*	Fax Number:	*

Information About Company Or Person Your Complaint Is About

Company or Person?
Complainee Last Name:	*	Complainee First Name:	*
Company Name:	*
Street Address:	*	City:	*
State:		Zip Code:	*
County:		Phone:	*
Fax Number:	*	E-mail Address:	*
Web Site Address:	*

Incident Information

Incident Date:	* *	Incident Time:	:
Incident Location:	* *
City or Township:	*	Zip Code:	*
County:	*	Lake/Stream:	*

Other Information

Is a court action pending?				YesNo
Do you have an attorney representing you on this matter?				YesNo
Are you willing to testify in court regarding this complaint?				YesNo
Did you complain directly to the business?		YesNo	If so, who?	*
What was the response from the business?			*
If no complaint was given to the business directly, why?			*
Was this complaint filed with any other agencies?		YesNo	If so, who?	*

Incident Detail * * Limited to 24000 characters
Please provide any additional relevant information. You have approximately 8-10 typed pages and you may paste text from word processing documents.


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I certify that the information on this form is true and accurate to the best of my knowledge. *
I consent to releasing to the Michigan Attorney General any information or document relative to the investigation of this complaint. By checking this box, I also certify that I have had the opportunity to review the Michigan Attorney General Privacy Policy before submitting this complaint.				* Read the Privacy Policy


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