THE FEDERAL OMBUDSMAN: COMPLAINT FORM

Please fill in this form and send it to: The Federal Ombudsman, Rue de Louvain / Leuvenseweg 48 box 6, 1000 Brussels or fax.: 02 289 27 28 or contact@federaalombudsman.be

Don’t forget copies of your earlier complaint letters, replies to them and other important documents.

From:

Surname (Ms/ Mr) …………………………………………………………………………

Given name ……………………………………………………………………………………………

Address …………………………………………………………………………………………......…

Post code ……………………………………………………………………………………………

Municipality ……………………………………………………………………………………..……

Country ………………………………………………………………………………….......…………

Telephone ………………………………………………………………………………..……………

Fax …………………………………………………………………………………........…………

E-mail address ……………………………………@…………………………………………...……


Date ………/………/………

Your signature: ………………………………………………………………………….………

My complaint relates to:

Please enter here the name of the government department you want to complain about. If it is not a government department, the Federal Ombudsman is unable to do anything for you, but where possible he will forward your complaint to another ombudsman. If you are uncertain whether it is a government department you want to complain about, please phone 0800 99 962 (between 09.00-12.30 and 13.30-17.00).

Name of the department ………………………………………………………………………………

Address ……………………………………………………………………………………...………

Post code …………………………………………………………………………………………

Municipality ……………………………………………………………………………………….

You are known to the government department under the reference : ……………………………

The problem is:

Please tell us what the problem is. Please use your own words. There is enough room to write, but please be as brief as you can. If the Federal Ombudsman needs further information from you, he will phone you or you will receive a letter (or e-mail).

If you have already written one or more complaint letters to the government department, please send us copies in any event, as well as the replies to them and other documents that are important to your case.

Please write as clearly as possible.

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