COMMISSION FOR LOCAL ADMINISTRATION IN WALES ALLEGATION OF A BREACH OF THE CODE OF CONDUCT FOR LOCAL AUTHORITY MEMBERS Please use black ink if possible and complete your name in block capitals. When you have filled in this form, send it to the Commissioner for Local Administration in Wales, Derwen House, Court Road, BRIDGEND, CF31 1BN.
	1.	Full Name(s) of person(s) making allegation:
	2.	Address:
	4.	Fax Number:
	5.	E-mail address:
	6.	Against whom is your allegation of a breach of the Code of Conduct being made?
	7.	Of which authority is the person against whom you are making the allegation a member?
	8.	What do you allege the member did wrong?
	9.	What provision(s) of the Code of Conduct do you say the member has breached? Note - you can obtain copies of the Code from the authority
	10.	In what way do you say that the member has breached the Code of Conduct?
	11.	When did the alleged breach occur?
	12.	What is your evidence for alleging that the member has breached the Code of Conduct? (Set out below the evidence and if necessary write on additional sheets. Attach copies of any relevant correspondence, papers, documents which you say support your allegation.)
	13.	Are there witnesses who can corroborate what you say? If so, set out below their full names, addresses and telephone numbers.
	14.	Have you made this allegation to the authority's Monitoring Officer? If so, when and what was the response?
	15.	Has the allegation been considered by the authority's Standards Committee? If so, when and what was the outcome?
		Note: By signing and returning this form to the Commissioner you are acknowledging that you understand that your identity will probably have to be made known to the member against whom you are making the allegation, to the authority of which he is a member and possibly to others who need to know who you are. You will also be confirming that you are prepared, if called upon to do so, to give oral evidence in public in support of your allegation to the authority's Standards Committee or any case tribunal which may be appointed by the President of the Adjudication Panel for Wales to consider any report which the Local Commissioner may issue if he decides to investigate your allegation.
		If you any documents to support your complaint, for example letters from the council, these can be sent to the Ombudsman with this form. Please tick the box if you would like them returned to you.
		Signature of person making allegation:
		Date of signature: