CASA of Tipton County, INC 
General Grievance Procedure
These are the instructions for reporting a general grievance or filing a complaint against a local CASA program, staff member or volunteer/advocate.
1. You may use this form to file a complaint against a Court Appointed Special Advocate volunteer, staff member, or the CASA of Tipton County program operating within the state of Tennessee. 
2. Please include a daytime telephone number or some other number where you may be reached to discuss your complaint. If your complaint arises out of a court case, you must provide the case number and the names of the parties who participated in the case. 
3. Please make sure that the complaint form is complete and accurate. You may use a 
separate letter to explain in your own words the circumstances that led to your complaint. Be as specific as possible in describing names, places, dates, and witnesses to the actions which gave rise to this complaint. List all the relevant events in the order they happened. Use additional sheets, if necessary, and attach copies of any documents that support your statement. If you wish to include court documents, please do not send the originals. 
4. Sign the complaint in the space provided. CASA of Tipton County cannot respond to 
anonymous complaints. 
5. Send the original complaint and the statement of facts to CASA of Tipton County: 
James Reece, Executive Director
PO Box 989
86 South Tipton St. 
Munford, TN 38058
Phone: 901-476-4114
 casatiptoncountytn@aol.com
Complaint Investigations: 
Complaint forms may be completed by anyone involved with or affected by the actions of the CASA program. The complaint and all attachments will be provided to the Board 
Chair and Director of CASA of Tipton County, if applicable, in order that the complaint 
may be addressed. 

GRIEVANCE FOR INVESTIGATION CONCERNING COURT 
APPOINTED SPECIAL ADVOCATES
COMPLAINT 
I hereby request an investigation in CASA of Tipton County, PO Box 989 Munford, Tennessee 38058.
STATEMENT OF FACTS 
1.	State below the specific details 0/ what forms the basis of your complaint. 
(Please type or print legibly and attach additional sheets if necessary.) 
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Date: _________________
		_ 
2. When and where did this happen 
Date: _____________________Time: _________________________ Location: 

3.lf your complaint arises out of a court case, please answer these questions: 
a) What is the name and number of the case? 
	Case name: _________________________	Case No: _______________________ 

Jurisdiction: ________________________________________________________

4). How are you interested in the case?
 
______ Staff ________Attorney _______ Family ______Advocate ________ Other

4. List of documents that support your complaint: 

Parent/Foster Parent  

I request that the above complaint, supported by the Statement of Facts, be 
investigated by CASA of Tipton County. I acknowledge that each local 
CASA program is governed by its own Board of Directors. 

Name: _____________________________________________________________ 

Address: ____________________________________________________________
Phone: Daytime (   ) 	__________________Evening (    ) ________________________

Signature: __________________________________________________________
Date: _______________________________________