Uniform Complaint Form

State of Florida
Department of Business and Professional Regulation
2601 Blair Stone Road
Tallahassee, FL 32399-1023

If you have any questions or need assistance in completing this form, please call the Customer Contact Center at 850-487-1395.

Please Note: An asterisk (*) designates a required field.
Please select a profession or business from the list below.*
Complaint Contact(s)*
Please select all applicable contacts related to this complaint.
- Self
- Private Attorney For Complainant
- Private Attorney For Subject Of Complaint
- Witness
- No Contact (File Anonymously)
Unlicensed Activity Complaint?*
- Yes
- No
- Unknown
Your Contact Information
Name
First Last
Your Company/Occupation
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone Number
Alternate Phone Number
Email Address
Subject Of Complaint
Name
First Last
License Number (if known)
Company/Occupation
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Email Address
Complaint Description
Private Attorney For Complainant
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone Number
Alternate Phone Number
Private Attorney For Subject Of Complaint
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone Number
Alternate Phone Number
Witness
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Phone Number
Alternate Phone Number
Complaint Agreement
Pursuant to Section 455.225, Florida Statutes, a complaint is legally sufficient if it contains ultimate facts that show that a violation of this chapter, of any of the practice acts relating to the professions regulated by the Department, or of any rule adopted by the Department or a regulatory board in the Department, has occurred. The Department may investigate, and the Department or the appropriate board may take appropriate final action on, a complaint even though the original complainant withdraws it or otherwise indicates a desire not to cause the complaint to be investigated or prosecuted to completion. Pursuant to Chapter 455, Florida Statutes, the complaint and all information obtained pursuant to the investigation by the Department are confidential and exempt from public records requests until 10 days after probable cause is found to exist, or until the subject of the investigation waives his or her privilege of confidentiality, whichever occurs first. However, the exemption does not apply to actions against unlicensed persons or unless otherwise provided by law. If an investigation of any subject is undertaken, the Department will contact you if additional information is needed. The Department will also furnish to the subject or the subject’s attorney a copy of the complaint or document that resulted in the initiation of the investigation. Should additional documentation be requested and not received by this Department within 30 days of the request, the file may be closed. Investigations differ in complexity and duration, so providing a time of completion is not possible. We appreciate your cooperation and understanding in this matter. Any investigation or administrative proceeding brought by the Department against the subject of your complaint will rely upon the information you provide to the Department. All allegations and supporting documentation MUST be provided to the Department if requested.*
Pursuant to Section 455.225, Florida Statutes, a complaint is legally sufficient if it contains ultimate facts that show that a violation of this chapter, of any of the practice acts relating to the professions regulated by the Department, or of any rule adopted by the Department or a regulatory board in the Department, has occurred. The Department may investigate, and the Department or the appropriate board may take appropriate final action on, a complaint even though the original complainant withdraws it or otherwise indicates a desire not to cause the complaint to be investigated or prosecuted to completion.

Pursuant to Chapter 455, Florida Statutes, the complaint and all information obtained pursuant to the investigation by the Department are confidential and exempt from public records requests until 10 days after probable cause is found to exist, or until the subject of the investigation waives his or her privilege of
confidentiality, whichever occurs first. However, the exemption does not apply to actions against unlicensed persons or unless otherwise provided by law.

If an investigation of any subject is undertaken, the Department will contact you if additional information is needed. The Department will also furnish to the subject or the subject’s attorney a copy of the complaint or document that resulted in the initiation of the investigation.

Should additional documentation be requested and not received by this Department within 30 days of the request, the file may be closed.

Investigations differ in complexity and duration, so providing a time of completion is not possible. We appreciate your cooperation and understanding in this matter.

Any investigation or administrative proceeding brought by the Department against the subject of your complaint will rely upon the information you provide to the Department. All allegations and supporting documentation MUST be provided to the Department if requested.
I Agree*

Your Contact Information

Subject Of Complaint

Private Attorney For Complainant

Private Attorney For Subject Of Complaint

Witness

Complaint Agreement

Resources

RESOURCES

MOBILE

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