Office of Consumer Affairs Case Specific Inquiry and Complaint Form

DFPS - HHS Enterprise Administrative Report and Tracking System (HEART)

Your Information

*First Name:		*Last Name:
*Address Line 1:		Address Line 2:
*City:		*State:
*Zip Code:
*DayTime Phone:		*Home Phone:
*Email:

Program

(Select "Other" located in the program drop down box if you are requesting an appeal of the Administrative Review of Investigation Finding process that identified your role as a designated perpetrator within a CPS case.)

*Program

*Intake Type

If other, then specify:

Caseworker Name( if known)

Victim's Information

*Your relationship to victim:

*First Name (Victim 1):	*Last Name:	Age:
First Name (Victim 2):	Last Name:	Age:
First Name (Victim 3):	Last Name:	Age:

Address Line 1:

Address Line 2:

*City:

State:

Zip Code:

County:

Parent's Information

Relationship:	Father	*First Name:		*Last Name:
Relationship:	Mother	*First Name:		*Last Name:

Describe inquiry or complaint

	*Describe inquiry or complaint(5,000 character limit):