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Name of Complainant * Age Sex Tel/Mobile Number Email Occupation of Complainant Postal Address Residential Address Region where the incident occurred *Select belowAhafoAshantiBono EastBrong AhafoCentralEasternGreater AccraNorth EastNorthernOtiSavannahUpper EastUpper WestWesternWestern NorthVolta District where the incident occurred *Select belowAsante Akim NorthAmansie EastEjisu JuabenMampongObuasiOffinsoKumasiAsunafo NorthBerekumDormaaKintampo NorthSunyaniTechimanWenchiCape CoastAgona WestAssin NorthEffutuKomenda/Edina/Eguafo/ AbiremKomenda/Eguafo/AbiremMfatsemanUpper Dekyira EastAkuapim SouthBirim CentralEast AkimKwahu WestNew JuabenWest AkimAdentaTemaAccraAshaimanGa EastGa WestLedzekuku‐KroworWeijaTamaleYendiBawkuBolgatangaWaHoHohoeKetaSecondi TakoradiNzema EastTarkwa NsuaemAdansi NorthAdansi SouthAfigya‐KwabreAhafo Ano NorthAhafo Ano SouthAmansie CentralAmansie WestAsante Akim SouthAtwima KwanwomaAtwima MponuaAtwima NwabiagyaBosome FrehoBosomtweEjura SekyedumaseKwabreOffinso NorthSekyere Afram PlainsSekyere CentralSekyereEastSekyere SouthAsunafo SouthAsutifiAtebubu AmantinDormaa East newJaman NorthJaman SouthKintampo SouthNkoranza NorthNkoranza SouthPruSeneSunyani WestTainTano NorthTano SouthAbura/Asebu/KwamankeseAgona EastAjumako/Enyan/EssiamAsikuma/Odoben/BrakwaAssin SouthAwutu SenyaGomoa EastGomoa WestTwifo/Heman/LowerDenkyiraUpper Denkyira WestAsikuma/Odoben/BrakwaAkuapim NorthAkyemansaAsuogyamanAtiwaBirim NorthBirim SouthFanteakwaKwaebibiremKwahu EastKwahu NorthKwahu SouthLower Manya KroboSuhum/Kraboa/CoaltarUpper Manya KroboYilo KroboDangme EastDangme WestBoleBunkprugu/YunyooCentral GonjaChereponiEast GonjaEast MamprusiGusheguKaragaKpandaiNanumba NorthNanumba SouthSabobaSavelugu/NantonSawla/Tuna/KalbaTolon/KumbunguBoleBunkprugu/YunyooCentral GonjaChereponiEast GonjaEast MamprusiGusheguKaragaKpandaiNanumba NorthNanumba SouthSabobaSavelugu/NantonSawla/Tuna/KalbaTolon/KumbunguBawku WestBongoBuilsaGaru/TempaneKassena Nankana WestKassena NankanaEastTalensi/NabdamJirapaLambussie KarniLawraNadowliSissala EastSissala WestWa EastWa WestAdaklu/AnyigbeAkatsiBiakoyeJasikanKadjebiKetu NorthKetu SouthKrachi EastKrachi WestNkwantaSouthNkwanta NorthNorth TonguSouth TonguSouth DayiKpandoAhanta WestAowin/SuamanBiaBibiani/Ahwiaso/BekwaiEllembeleJomoroJuabosoMpohor/Wassa EastPrestea/Huni ValleySefwi AkontobraSefwi/WiawsoShama newWassa Amenfi EastWassa Amenfi West Name of the Person/Organization against whom the complaint is being made (Respondent) Postal Address Email Tel./Mobile Phone Residential Address Facts What do you want CHRAJ to do for you? Authentication * I certify that all the information I have provided above is the true reflection of my petition to the Commission and by filling the space below with my name constitutes authenticating this petition as required by Regulation 1(3) (c) of CHRAJ (INVESTIGATIONS PROCEDURE REGULATIONS, 2010 [C.I. 67]) which provides: "A complaint made in writing may be addressed to the Commissioner or the Commissioner’s regional or district representative and the complainant shall authenticate, the written complaint." Submit