APPENDIXA-CSOFundingPoolComplaintForm

Beforelodgingacomplaint

Before lodging acomplaintwiththe CSOFundingPoolAdministration Agency(the Agency),itmaybeusefultocontacttheAgencytollfreeinVICon 1300309213todiscussyour complaint or seekassistance.

Complaintscanbelodged withthe Agencyin writing,either electronically or in hardcopy, tothefollowing address:

Email:x:0396394459

Post:ComplaintsOfficer CSOFunding PoolAdministrationAgencyLockedBag32005CollinsSt East, VIC8003

Iwantto lodgea formalcomplaintwiththeCSO FundingPoolAdministrationAgency Yes No

My detailsare:

Mr/Mrs/Ms(other)FirstName:Last Name:Address:______

Postcode:State:______

Telephone:(businesshours)

Mobile:Fax:Emailaddress:______I am lodging thiscomplaintonbehalf of:Myself (goto page 2oftheform)

Anothercompanyorperson(completethe detailsbelow)

Details ofthecompany or person who wasaffectedby theactions or servicethatyou wishtocomplain aboutare:

Mr/Mrs/Ms(other)First NameLast Name:______

Or companyname:______

Address:______

Postcode:State:______

Telephone:(businesshours)______Mobile:Fax:______Emailaddress:______

Is the personor companyawareyou aremakingthiscomplaint?YesNo

Myrelationship withthecompany orpersonis(for exampleshareholder,director,businesspartner,familymember):

Iwanttocomplain about:

□TheCSO Funding PoolAdministrationAgency

□ The NDSS Administrator’s administration of payments for NDSS

distribution services

□CSODistributor One

CSODistributor Name:______

CSODistributor contactdetails(ifknown):______

□CSODistributorTwo

CSODistributor Name:______CSODistributor contactdetails(ifknown):______

If therearemore CSODistributorsyouwant tocomplainabout please attachtheirdetailson aseparatepieceof papertotheback of thisform.

□AnotheraspectoftheCSO FundingPoolMy complaintis:

Usethe spacebelow to providedetails ofyour complaint. Itisusefultoincludewhathappened,when

ithappened andwho wasinvolved.Include as muchsupportinginformation andevidenceas youcan(attach any relevantdocumentsyou havetothe backofthisform). If youneed morespace,pleaseattachaseparate piece ofpaper tothebackofthisform.

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The main issues I amconcerned aboutare: ______

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As a resultofmycomplaint I want:

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Wherethiscomplaintisagainsta CSO Distributor, haveyouapproachedtheCSODistributorabout thiscomplaint? Yes NoIf yes, whatwastheoutcome?

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Haveyoucomplainedtoanotherorganisationaboutthesamematter? Yes No

If yes.pleasegive details.

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The Agencywillsend detailsofthiscomplainttoanyCSO Distributor/syou haveidentified inyourcomplaintasking themto provide a responsetothe Agency.

Iagreethatmyidentitycanbe released forthispurpose - Yes No

Youdonothaveto agreeto therelease of your identity.

Iagreethata copyofmycomplaintcan be releasedfor thispurpose? Yes No

Youdonothaveto agreeto release acopyofthiscomplaint. If you select'No',you needto advisebelowanyinformationinthisform that youdo notwantreleased tothe subject ofthecomplaint(egyour name,othersnames,other detailsaboutthecomplaint).

Signature: ______

Date: ______