MVI Complaint Receipt (SHP-516) — Missouri State Highway Patrol

Accessible Web Version. This is an accessible HTML version of form SHP-516.

Complaint Information

Type of Complaint

Date Received

Time Received

Complainant

Name (Last, First, MI)

Address (Street, Rte, City, State, ZIP)

Home Telephone

Business Telephone

Best Time to Contact

Inspection Station Involved

Name of Station

Station Number

Sticker / Decal Number

Name (Last, First, MI) of Inspector / Mechanic

I/M Number

Approval / Rejection Number

Vehicle Information

Year

Make

Model

VIN

Inspection Mileage

Reinspection Mileage

Witnesses

Witness 1 — Name (Last, First, MI)

Witness 1 — Home Telephone

Witness 2 — Name (Last, First, MI)

Witness 2 — Home Telephone

Witness 3 — Name (Last, First, MI)

Witness 3 — Home Telephone

Witness 4 — Name (Last, First, MI)

Witness 4 — Home Telephone

Complaint Details

How Was the Complaint Received?

In Person Phone Mail Other

If Other, please specify

Received By (Employee Taking Complaint)

Troop

Complaint No. (MVI Use Only) Assigned by MVI

Location of Incident

Date Occurred

Time Occurred

Brief Description of Incident

Will Complainant Testify at a Hearing?

Yes No

Does Complainant Wish to Remain Anonymous?

Yes No

Complainant's Affirmation

I do solemnly swear or affirm that the above information is true to the best of my knowledge. I understand that based on this complaint, an investigation will be conducted and that if substantiated, appropriate action will be taken.

Signature of Complainant (Type Full Name) By typing your name, you are providing your electronic signature

Date

Investigation (MVI Use Only)

Investigation Assigned To

Date Assigned

Complaint Resolved

Is the Complaint Resolved?

Yes No

Describe Resolution

Senior MVI Supervisor Signature

Date