Date Received: For Office Use Only Form 4-65 (08/18) COMPLAINT FORM (Please complete a separate form for each location.) Instructions: Use this form to complain about possible violations of the law on TABC-licensed premises or to report possible alcohol-related violations taking place at any location. Provide a copy of this form to your local TABC Office; or mail it to TABC Enforcement Division, PO Box 13127, Austin, TX 78711; or fax it to 512-206-3449; or email to firstname.lastname@example.org . For more information about complaints or to locate the nearest TABC Office visit: http://www.tabc.texas.gov . Please notify me of the outcome of this complaint. If you wish to remain anonymous, we may not be able to notify you of the outcome of the complaint. Email Address: Information provided below is subject to the Public Information Act and will be disclosed to the public upon request, as required by law. Only e-mail addresses are considered confidential under law and any other identifying information could be released to the public. Your Contact Information: Anonymous If you wish to remain anonymous, you must leave this section blank. Your Name: Mailing Address: City: State: Zip Code: Phone: Day: ( ) 226 Evening: ( ) - Other: ( ) - Where did the possible violations take place? Name of Location: Address: City: County : Zip Code: Phone: ( ) - Other: ( ) - Name of Business or Property Owner(s), if known: Date(s) / Time of Day: Day(s) of the week : Sunday Monday Tuesday Wednesda y Thursday Friday Saturday Details of the Complaint (What violations were committed and who committed them?) American LegalNet, Inc. www.FormsWorkFlow.com
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