Request for Review

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* 1. Contact Information

Name

Company

Address

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 2. Product, Item, Service to Review

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* 3. Account #/Location in question

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* 4. Date(s) in question

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* 5. Details. Please describe the situation you would like reviewed.

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* 6. Have you previously contacted anyone about this?

If yes, who and when:

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* 7. Have you contacted an attorney?

If Yes, please provide name and phone number.

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* 8. Resolution Requested. What result would you consider fair?

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* 9. In submitting this, I understand that Delta City is not my private attorney. I further understand that if I have any questions concerning my legal rights or responsibilities that Delta City cannot give me legal advice and I should contact a private attorney. I understand that this information and any materials I provide to Delta City are records under the Utah Government Records Assessment and Management Act are governed by the Act. I hereby give my consent and disclosure of this information for the purpose related to an investigation by Delta City and attest that the information is true and accurate to the best of my knowledge and belief. I understand that my cooperation is necessary and that Delta City my close its investigation without sufficient cooperation.

I agree