BESPECIFIC Please submit your grievance without accusatory blame… Will you be forgving? * ...with an attitude of gratitude. Yes No Still Unsure CONSENT * Does the nature of this grievance pertain to a consent violation? YES NO FRAUD * Does the nature of this grievance pertain to fraudulent charges? YES NO TRUST * Does the nature of this grievance pertain to broken trust? YES NO DESCRIBE YOUR GRIEVANCE IN DETAIL: * How much compensation is owed? If none leave blank. $ VALIDATION STATUS * VALIDATED PENDING VALIDATION UGI Enter your Unique Grievance Identifier. Are you the innocent party? * YES NO How strongly would you agree with the statement below? * "This complaint is trustworthy." Strongly Disagree Disagree Neutral Agree Strongly Agree