*Please fill in the form and fax it to whichever complaint center that is suitable. Also, please ensure that you have filled in your name, identity card number, address and date. If you have any documents / evidence to support your claims, please enclose together with this form. Only one complaint is permitted for every form.
Name : ________________________________________________________________________________
Identity Card Number : _______________________________
Address: ______________________________________________________________________________
_____________________________________________________________________________________
Post Code:_______________________ State: _______________________________
Tel (H): ______________Tel (O): _____________________ Fax: __________________
Email: _________________________
Information on Voting Constituency
State : ____________________________________
State Assembly : ___________________________________________
Parliament : ________________________________________________________
Category of Complaint
Based on your assessment, please tick any one of the categories below that best represents the nature of your complaint. :
q Voters List q Postel Votes q Physical Violence
q Heavy offences q Extortion q Phantom Voters
q Shifting of voting constituency q Voting Twice q Vote Buying
q Corruption q Cheating q False Identity Cards
q Missing Ballot Boxes q Kidnap q Misuse of Media
q Misuse of Power q Broken seal on ballot box before vote counting
q Others (Please State) ___________________________________________________________
Details of Report
1. Did you directly witness the incident? If no please state the name and address of the witness?
________________________________________________________________________________
2. Did the incident involve any kind of threat or intimidation (for example, threat of attempted violence or others)?
q Yes q No
3. If yes, was it
q Serious q Limited q Not Serious
4. Did the incident involve physical disturbances or program / activity disruptions? (for example, cutting off electricity supply or pulling away the microphone during a political rally)
q Yes q No
5. If yes, was it
6. Where did the incident take place?
q Political Rally q Meeting q Polling Centre
q Others (Please State) ____________________________________
7. Who started the incident?
q Authorities (Please state) __________________________________________
q Individual
q Others (Please State) _____________________________________________
8. Which party was victimized in the incident?
q Authorities (Please State) _________________________________________
q Individual
q Others (Please State) ______________________________________________
9. What actions did the relevant authorities take towards the incident?
q Restored calm to the situation
q Provoked further tension to the situation
q Remained neutral
q Others (Please State)
_______________________________________________
10. Explain how the incident transpired
________________________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
1 admit that my report above is true.
___________________________________
Signature of Complainant