Office of the Crime Victims' Ombudsman
1205 Pendleton Street
Columbia, South Carolina 29201
Phone: 803.734.0357
Fax: 803.734.1428

All fields marked by an "*" are required fields.

Section 1: Victim Information 


* First Name 


* Last Name 

* Address 

Suite/Apartment Number 

* City 

* State 

* Zip 

* Email 

* Contact PhonPhone 


Section 2: Complainant Information (Complete only if different from above) 


First Name 


Last Name 

* Address 

Suite/Apartment Number 





Contact Phone 


Section 3: Crime Information 

Suspect's Name 


Suspect's Relationship to Victim, if any: 


Type of Crimes/Charges: 


Date of Crime: 


County In Which the Crime Occurred: 


Law Enforcement Agency Contacted: 


Case Number and/or Warrant Number 


Name of Investigating Officer: 


Section 4: Complaint Information 

What Agency Complaint is Against: 


Victims' right(s) you feel were violated: 


How would you like the Office of the Crime Victims' Ombudsman to help: 


Section 5: Victim Service Provider/Victim Advocate 

Have you spoken with an advocate? 


Advocate's Name: 


Advocate's Agency: 


Section 6: Referral Service 

Referral Service: 


If other, please specify: 


Section 7: Consent to Investigate 

In order to conduct an inquiry into your complaint, the CVO shall forward copies of your complaint to the person, program, and agency against whom you make the allegation, and conduct an inquiry into the allegation stated in the complaint. In carrying out the inquiry, the CVO is authorized to request and receive information and documents from the complainant, elements of the criminal and juvenile justice systems, and victim assistance programs that are pertinent to the inquiry. Following each inquiry, the CVO shall issue a report verbally or in writing to the complainant and the persons or agencies that are the object of the complaint and recommendations that in the ombudsman's opinion will assist all parties. The persons or agencies that are the subject of the complaint shall respond, within a reasonable time, to the CVO regarding actions taken, if any, as a result of the CVO's report and recommendations. By inserting your name below, you are giving your consent to the CVO to disclose this information to the agency stated in your complaint. I understand that upon receipt of this form, the Office of the Crime Victims' Ombudsman will conduct an inquiry into my complaint and I hereby consent to such an investigation. I certify that I have read and understood all of the above statements.

* Signature: 


* Date: 


SECTION 16-3-1640# Confidentiality of information and files. Information and files requested and received by the ombudsman are confidential and retain their confidential status at all times. 

Section 8: Statement of Complaint 

Please provide as much detailed information about the crime and your complaint as possible. Use additional paper if necessary. You may also attach any other documentation you feel is necessary to the inquiry. Be sure to include what agency/entity your complaint is against. 


The Statement of Complaint field holds 4000 characters. If you need to submit more information, please email additional information to

I certify that the information set forth herein is true and correct.

* Certification Signature: 


* Certification Date: