Citizen Complaint Form

Date of Event: (required)

Time of Event: (required)

First Name (required)

Middle Initial

Last Name (required)

Phone Number (required)

Are you willing to come before the Board of Directors for the Millersville Rural Fire Protection District with this complaint? (required)

Yes

Details of your complaint: (required)

Witnesses: Name & Phone Numbers

I hereby certify that the statements given by me herein are true and accurate to the best of my personal knowledge. I understand that making intentional false declarations to public servants or untrue statements under oath or affirmation may be punishable by law. I further understand that I must personally sign this complaint in order for it to be valid, and that false reporting in an attempt to unjustly subject a member to undeserved discipline or slander, or place his/her membership in jeopardy, can result in criminal charges.

Your Signature (required)

Confirm e-Signature

Review Electronic Records and Signatures Policy (required)

Read our Electronic Record and Signature Disclosure

I agree to use electronic records and signatures

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