Preview Public Employee Complaint

STATE OF NEW HAMPSHIRE

DEPARTMENT OF LABOR

PO BOX 2076

CONCORD, NH 03302-2076

COMPLAINT FORM

FOR PUBLIC EMPLOYEES

Filed pursuant to RSA 275-E:8

COMPLAINANT INFORMATION

Name____________________________________________________ S.S. No. (optional)_________________

Mailing Address_____________________________________________ Tel.___________________________

(Street) (City) (State) (Zip)

EMPLOYER INFORMATION

Name of Employer /Public Entity_______________________________________________________________

Mailing Address____________________________________________________________________________

(Street) (City) (State) (Zip)

Contact Person______________________________________________ Tel.____________________________

Are you reporting: (check all that apply)

Fraud in expenditure of public funds Fraud relating to programs involving procurement of supplies,

services or construction by governmental entities within the state

Waste in expenditure of public funds Waste relating to programs involving procurement of supplies,

services or construction by governmental entities within the state

Abuse in expenditure of public funds Abuse relating to programs involving procurement of supplies,

services or construction by governmental entities within the state

Please be as specific as possible with detailed information regarding the basis of your complaint: ____________

__________________________________________________________________________________________

CERTIFICATION

I hereby certify that this is a true statement of the facts as is involved in this matter.

Signature_____________________________________________ Date_________________________________

I give the New Hampshire Department of Labor the authority to disclose my identity if my complaint is deemed

to have merit.

(optional) Signature __________________________________________ Date___________________________

Please be advised that if this complaint is referred for a criminal investigation your identity shall be disclosed without

your consent.

Rev. 2/15/14

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