Nama Penuh/Full Name: _________________________________________________________

No. K.P/IC No. : _____________________________ Jantina/Gender : Lelaki/Male Wanita/Female

Alamat/ Address : _________________________________________________________

Poskod/Post Code : ________________ Negeri/State: ________________________________

Tel (Rumah/Res.) : ________________ Tel (Pejabat/Off): _____________ Fax: _____________

E- Mail : ________________________________________________________

Rahsiakan butir pengadu/Complainants identity to be kept confidential Ya/Yes Tidak/No

Negeri/State: ______________________ Dewan Undangan Negeri/State Assembly: ____________________

Kawasan Parlimen/Parliamentary Constituency: ______________________

 Kategori Aduan/Complaints Category (sila pangkah/please tick):

Senarai Daftar Pemilih/ Voters List Undi Pos/ Postal Votes

Penyalahgunaan Kuasa & Harta Awam Intimidasi/Gangguan Ugutan/Kekerasan Fizikal

Misuse of State Resources /Authority Intimidation / Harassment/ Physical Violence

Rasuah & Korupsi/ Corruption & Bribery Lain-lain/Others

Keterangan lanjut mengenai aduan / Description of complaint :

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

(sila nyatakan tarikh & masa / please state date & time]

_____________________________________________________________________________________________________________

Nama Pihak terlibat (jika tahu) / Name of Person concerned (if known): ____________________________________________________

Adakah pengadu sendiri terlibat? Is the complainant involved? Ya/ Yes Tidak/ No

Jika tidak, sudahkah anda pastikan kebenarannya? If no, did you verify the truth? Ya/ Yes Tidak/ No

Sila terangkan / Please explain: ____________________________________________________________________________________

_______________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Nama orang yang melakukan (jika tahu) / Name of perpetrator (if known): ___________________________________________________

Keterangan Tambahan/ Additional Detail: _____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Saya dengan ini mengakui kebenaran laporan ini/ I confirm my report above is true.

________________________________________

Tandatangan Pengadu/ Signature of Complainant Hantarkan kepada / Send to:

Pertubuhan Kebajikan BUDI Malaysia (Biro Aduan)