Section A

Your Details

Your name in full

Address

Postcode

If you provide an email address we will normally use this for correspondence.

Daytime contact number

Mobile number

Ombudsman’s case reference number(s) if known

The person who submitted the complaint about a public body, or who experienced the problem with our services should normally fill in this form. If you are filling this in on behalf of someone else please fill in Section B.

Section B

If you are requesting a review and/or making a comment/complaint on behalf of someone else, please provide their details.

Their name in full

Their Address

What is your relationship to them?

Why are you acting on their behalf?

Section C

Do you want to ask us to review a decision by the Ombudsman about a complaint involving another public body?

Do you want to comment or complain about the standard of service you have received from us?

Please contact us if you need any help completing this form

Section D

Your request for a review of a decision taken by the Ombudsman

What was the date of our decision?

If it was more than 20 working days ago, please explain why your review request has been delayed.

What do you want the review to look at?

What new evidence do you have?

What evidence do you think we have not taken into account and how do you think it affected our decision? You will need to provide this for each aspect of your review request.

Remember: we will not be able to look at your review request if you simply disagree with our decision.

If you have documents to support your request, please submit them with this form

Section E

Your comment or complaint about the service provided by the Ombudsman

What is your comment or complaint about the Ombudsman’s service?

How did this affect you?

When did this happen?

Have you raised this informally?

Who did you deal with?

How can we put things right or improve our service?

If you have documents to support your comment or complaint, please submit them with this form.

Section F

Please list any documents attached or provide any additional information

Please list any documents attached or provide any additional information

File Upload 1

File Upload 2

File Upload 3

File Upload 4

File Upload 5

If you need to attach more than 5 documents, please email them to feedback@ombudsman.wales

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