Appendix R · Digital companion · all tools
Ready-to-use forms for any claim
Appendix R: The Model Public Accounting Forms
A reform method becomes usable when citizens, officials, lawyers, students, journalists, workers, patients, heirs, and local groups can put it into forms. Forms are not glamorous. They do not carry the emotional force of a manifesto. But forms are where rights become recordable. A complaint that remains in speech can be denied. A complaint that enters a form begins to travel through a process. A public duty that is not recorded can disappear. A public duty placed in a form can be tracked, compared, appealed, and remembered.
This appendix gathers model forms for the most important public accounting functions discussed throughout the book. They are designed to be adapted. They are not legal substitutes. They do not replace statutory formats, court pleadings, official applications, or professional advice where those are required. Their purpose is to provide disciplined starting points.
Each form follows the same logic: identify the duty, record the facts, preserve the evidence, request the remedy, protect the claimant, and create a follow-up date.
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Form 1: Basic Citizen Claim Form
*Purpose: To convert a general grievance into a structured claim.*
A translated version of any form or letter is a draft for your understanding. Submit in the office’s official language, and have the final text checked by someone you trust.
Claimant name: [Insert] Protected reference, if anonymity is needed: [Insert] Contact method: [Insert] Date claim prepared: [Insert] Issue category: [Service delay, wage, inheritance, police, health, education, local government, land, pension, other] Office, person, employer, institution, or authority involved: [Insert] What I am claiming: [Insert the specific service, payment, document, record, protection, correction, or remedy] What was owed: [Insert] Who owed it: [Insert] Date the issue began: [Insert] What I submitted or requested: [Insert] Receipt, tracking number, or proof of submission: [Insert] Response received: [Insert] Delay, refusal, harm, or failure: [Insert] Evidence attached: [Insert list] Written reasons received: [Yes or no] Appeal or complaint already filed: [Yes or no] Retaliation or privacy risk: [Low, medium, high] Remedy requested: [Insert] Next follow-up date: [Insert] Consent for public use of information: [No, anonymous only, aggregate only, public with name]
This form should be the first file in a citizen claim folder. It helps prevent the claim from becoming emotionally large but administratively unclear.
Form 2: Timeline Form
*Purpose: To show what happened and when.*
Claim reference: [Insert] Issue: [Insert] Date prepared: [Insert] Timeline entries: Date: [Insert] Event: [Insert] Person or office involved: [Insert] Evidence: [Insert] Next promised action: [Insert] Date: [Insert] Event: [Insert] Person or office involved: [Insert] Evidence: [Insert] Next promised action: [Insert] Date: [Insert] Event: [Insert] Person or office involved: [Insert] Evidence: [Insert] Next promised action: [Insert] Summary of delay: [Insert] Timeline gap or missing evidence: [Insert]
A timeline is often more powerful than a long complaint. It shows whether the citizen waited, returned, submitted, followed up, and was ignored.
Form 3: Receipt Request Form
*Purpose: To request acknowledgment of submission where an office does not automatically provide it.*
To: [Office or institution] Date: [Insert] Subject: Request for receipt or acknowledgment of submission I submitted the following application, complaint, document, or request: Service or issue: [Insert] Date submitted: [Insert] Documents submitted: [Insert] Receiving desk or officer, if known: [Insert] I respectfully request a receipt, tracking number, stamped copy, or written acknowledgment confirming that the submission has been received. Please also provide the expected processing timeline and the method for checking status. Applicant name: [Insert] Contact: [Insert] Signature: [Insert]
If the office refuses receipt, the citizen should note the refusal in the visit log and consider submitting through another official route that creates proof.
Form 4: Written Reasons Request Form
*Purpose: To request reasons for delay, refusal, return, or incomplete status.*
To: [Office or institution] Date: [Insert] Subject: Request for written reasons I submitted or requested the following: Application, complaint, or service: [Insert] Receipt or tracking number: [Insert] Date of submission: [Insert] I have been informed that the matter is delayed, refused, returned, incomplete, or not being processed. Please provide written reasons identifying: The specific issue. The rule, requirement, or document involved. What correction, if any, is required from my side. The appeal or review route if I disagree. The expected timeline for further action. Applicant name: [Insert] Contact: [Insert] Signature: [Insert]
Written reasons are essential because they turn vague refusal into something the citizen can correct or challenge.
Form 5: Public Service Delay Complaint Form
*Purpose: To complain about a routine service not completed within a reasonable or published timeline.*
Service name: [Insert] Office: [Insert] Applicant name: [Insert] Receipt or tracking number: [Insert] Date submitted: [Insert] Published or promised timeline: [Insert] Date timeline expired: [Insert] Status given by office: [Insert] Written reason provided: [Yes or no] Documents submitted: [Insert] Number of visits or follow-ups: [Insert] Evidence attached: [Insert] Impact of delay: [Insert] Remedy requested: [Completion, written reason, appeal review, urgent processing, correction, other] Complaint submitted to: [Insert] Complaint date: [Insert] Complaint tracking number: [Insert]
This form is suitable for transcripts, certificates, pensions, utility corrections, land records, public office services, and similar matters.
Form 6: Wage Claim Form
*Purpose: To record unpaid or delayed wages.*
Worker name: [Insert] Employer or contractor: [Insert] Workplace: [Insert] Type of work: [Insert] Work start date: [Insert] Work end date or current status: [Insert] Agreed wage: [Insert] Payment schedule: [Daily, weekly, monthly, project-based, other] Hours or days worked: [Insert] Amount paid: [Insert] Amount unpaid: [Insert] Deductions disputed: [Insert] Date payment was due: [Insert] Reason employer gave for non-payment: [Insert] Evidence attached: [Messages, attendance, photos, witnesses, partial payment proof, uniform, duty roster, other] Still employed: [Yes or no] Retaliation risk: [Low, medium, high] Immediate hardship: [Rent, food, medical, school fees, debt, other] Remedy requested: [Full payment, settlement, payment schedule, anti-retaliation protection, other] Complaint filed with: [Insert] Tracking number: [Insert]
A wage claim should be kept factual. The worker should avoid signing any document stating payment was received unless payment has actually been received.
Form 7: Employer Wage Response Form
*Purpose: To give the employer a fair opportunity to respond.*
Employer name: [Insert] Worker name or reference: [Insert] Claim received date: [Insert] Employment admitted: [Yes, no, partly] Work period admitted: [Yes, no, partly] Agreed wage admitted: [Yes, no, partly] Amount paid: [Insert] Amount unpaid admitted: [Insert] Dispute over amount: [Insert] Dispute over attendance: [Insert] Dispute over performance: [Insert] Reason for non-payment or delay: [Insert] Payment proposal: [Insert] Date payment will be made: [Insert] Evidence attached: [Payroll, receipts, attendance, bank transfer, other] Employer commitment against retaliation: [Yes or no] Signature or verification: [Insert]
This form helps distinguish genuine disputes from wage theft and creates a written basis for settlement.
Form 8: Wage Settlement Form
*Purpose: To record a wage settlement clearly.*
Worker name: [Insert] Employer name: [Insert] Work period: [Insert] Amount claimed: [Insert] Amount agreed: [Insert] Payment date: [Insert] Payment method: [Cash, bank transfer, mobile wallet, other] Payment proof required: [Yes] Settlement covers: [Insert wage period] Does settlement include deductions? [Yes or no. If yes, explain] Employer agrees not to retaliate: [Yes] Worker confirms settlement is voluntary: [Yes] Complaint route if payment is not made: [Insert] Witness or officer: [Insert] Date: [Insert] Signatures: [Insert]
A settlement is not complete until payment proof is attached.
Form 9: Female-Heir Inheritance Safeguard Form
*Purpose: To protect women from being erased or pressured out of property rights.*
Property reference: [Insert] Deceased person reference: [Insert] Female heir name: [Insert] Relationship to deceased: [Insert] Share identified: [Insert] Estimated value, if available: [Insert] Was heir separately notified? [Yes or no] Was share explained in plain language? [Yes or no] Did heir receive copy of relevant record? [Yes or no] Did heir have access to independent advice? [Yes or no] Is relinquishment proposed? [Yes or no] If relinquishment is proposed, is it full or partial? [Insert] Is compensation offered? [Yes or no. If yes, amount] Does heir understand that relinquishment may be final? [Yes or no] Was heir interviewed separately from benefiting parties? [Yes or no] Any sign of pressure, threat, dependency, or coercion? [Yes or no] Legal aid information provided: [Yes or no] Cooling period applied: [Yes or no] Complaint route provided: [Yes or no] Officer or verifier: [Insert] Date: [Insert]
This form should be treated as a safeguard, not a mechanical checkbox. The goal is real consent, not faster paperwork.
Form 10: Inheritance Coercion Complaint Form
*Purpose: To report pressure, threat, misrepresentation, or exclusion in inheritance.*
Complainant name: [Insert] Relationship to deceased: [Insert] Property reference: [Insert] Date of death: [Insert] Heirs known: [Insert] My name appears in record: [Yes, no, unknown] I received notice: [Yes, no, unknown] I was asked to sign documents: [Yes or no] Documents signed: [Insert] Did I understand the documents? [Yes or no] Pressure or threat alleged: [Insert] Person or persons involved: [Insert] Documents withheld from me: [Insert] Evidence attached: [Messages, documents, witnesses, audio where lawful, other] Immediate safety risk: [Low, medium, high] Remedy requested: [Record correction, cancellation of relinquishment, legal review, protection, copy of documents, other] Complaint submitted to: [Insert] Tracking number: [Insert] Privacy level: [Restricted, anonymous public, public]
Inheritance coercion cases require safety assessment before public disclosure.
Form 11: Police Complaint Acknowledgment Request
*Purpose: To ensure a police complaint leaves a record.*
To: [Police station] Date: [Insert] Subject: Request for complaint acknowledgment I am submitting a complaint regarding: Nature of complaint: [Insert] Date and location of incident: [Insert] Persons involved, if known: [Insert] Immediate safety risk: [Insert] Evidence attached: [Insert] I respectfully request written acknowledgment of receipt, a complaint number, and information on the next step. If the matter is not registered as a formal case, please provide written reasons and the review route. Complainant name: [Insert] Contact: [Insert] Signature: [Insert]
A citizen should keep a copy of the written complaint and any acknowledgment.
Form 12: Police Non-Registration Review Form
*Purpose: To seek review when police refuse to register or act.*
Complainant name: [Insert] Complaint number, if issued: [Insert] Police station: [Insert] Date complaint submitted: [Insert] Nature of complaint: [Insert] Written reasons for non-registration received: [Yes or no] If yes, reasons given: [Insert] Why I request review: [Insert] Immediate safety concern: [Insert] Evidence attached: [Insert] Remedy requested: [Registration, written reasons, referral, protection, senior review, other] Submitted to: [Senior officer or review authority] Date: [Insert] Review tracking number: [Insert]
This form does not assume the allegation is proven. It asks that refusal be reviewed.
Form 13: Patient Medicine Unavailability Complaint
*Purpose: To record when a public hospital patient is asked to buy medicine outside.*
Hospital: [Insert] Department or ward: [Insert] Patient reference: [Protected] Date: [Insert] Medicine prescribed: [Insert] Strength or form: [Insert] Prescribing doctor or department: [Insert] Is medicine on hospital free or subsidized list? [Yes, no, unknown] Pharmacy response: [Available, out of stock, buy outside, unknown] Was stockout recorded? [Yes, no, unknown] Outside purchase cost: [Insert] Could patient afford it? [Yes, no, partly] Receipt from outside purchase: [Yes or no] Complaint submitted to: [Insert] Complaint number: [Insert] Remedy requested: [Medicine availability, reimbursement review, stockout explanation, complaint review, other] Privacy level: [Restricted]
This form should protect patient identity and medical privacy.
Form 14: Hospital Patient Rights Complaint Form
*Purpose: To report a hospital service failure.*
Hospital: [Insert] Patient reference: [Protected] Date and time: [Insert] Department: [Insert] Complaint category: [Medicine, fee, emergency delay, equipment unavailable, rude behavior, privacy violation, referral, overcharging, cleanliness, other] Description: [Insert] Official fee receipt attached: [Yes or no] Medicine or test prescription attached: [Yes or no] Immediate health risk: [Low, medium, high] Complaint submitted to: [Insert] Complaint number: [Insert] Response due by: [Insert] Remedy requested: [Insert]
Privacy warning: Patient information should not be public unless consent is clearly given and risk is reviewed.
Form 15: Local Government Complaint Form
*Purpose: To record ward-level service failures.*
Ward: [Insert] Location: [Insert] Complaint category: [Waste, drain, streetlight, road, footpath, park, encroachment, water, sewerage, public toilet, market, building safety, other] Date observed: [Insert] Description: [Insert] Photograph attached: [Yes or no] Public safety risk: [Low, medium, high] Complaint submitted to: [Insert] Complaint number: [Insert] Expected response date: [Insert] Status: [Pending, in progress, resolved, delayed, referred] Reason for delay, if any: [Insert] Completion evidence: [Insert]
This form works best when paired with photographs, dates, and exact location.
Form 16: Public Project Board Missing Information Form
*Purpose: To report missing or incomplete public project information.*
Project location: [Insert] Project type: [Road, drain, building, park, water, sewerage, other] Date observed: [Insert] Project board present: [Yes or no] If present, information shown: Project name: [Yes or no] Authority: [Yes or no] Contractor: [Yes or no] Cost: [Yes or no] Start date: [Yes or no] Completion date: [Yes or no] Complaint route: [Yes or no] Photograph attached: [Yes or no] Information requested: [Insert] Submitted to: [Insert authority] Tracking number: [Insert]
Public work without public information should be treated as incomplete accountability.
Form 17: Public Records Request Form
*Purpose: To request records from a public body.*
To: [Authority] Date: [Insert] Subject: Request for public record I request the following record or information: [Describe record clearly] The record relates to: [Service, land, project, procurement, hospital, school, tax expenditure, ward budget, complaint, other] Location or reference: [Insert] Time period: [Insert] Purpose of request: [Public accounting, citizen service, research, legal claim, other] Please provide the record, or written reasons if it cannot be provided. If only part of the record can be provided because of privacy or legal restrictions, please provide the public portion and identify the reason for withholding the rest. Requester name: [Insert] Contact: [Insert] Signature: [Insert]
This form should be adapted to the relevant right-to-information or public-record law where applicable.
Form 18: Public Record Correction Request
*Purpose: To correct wrong or missing public records.*
To: [Authority] Date: [Insert] Subject: Request for correction of public record Record involved: [Insert] Record reference number: [Insert] Current entry: [Insert] Correction requested: [Insert] Reason correction is needed: [Insert] Evidence attached: [Insert] Harm caused by incorrect record: [Insert] Urgency: [Insert] Please provide a receipt or tracking number and a written decision. If correction is denied, please provide written reasons and the appeal route. Applicant name: [Insert] Contact: [Insert] Signature: [Insert]
Record correction is essential because wrong records can damage property, pension, education, welfare, tax, identity, and legal claims.
Form 19: Media Follow-Up Ledger Entry
*Purpose: To track what happened after a public story.*
Story title: [Insert] Date first reported: [Insert] Issue category: [Insert] Location: [Insert] Public duty involved: [Insert] Initial claim: [Insert] Evidence cited: [Insert] Authority response: [Insert] Records requested: [Insert] Committee or inquiry announced: [Yes or no] Promise made: [Insert] Deadline: [Insert] Follow-up date: [Insert] Current status: [Open, partly resolved, resolved, disputed, no action] Remedy achieved: [Insert] Records still missing: [Insert] Next follow-up: [Insert]
This form prevents public stories from disappearing into amnesia.
Form 20: 90-Day Pilot Charter Form
*Purpose: To define a small public accounting pilot.*
Pilot name: [Insert] Issue: [Insert] Location: [Insert] Duration: 90 days Public duty examined: [Insert] Records to collect: [Insert] Citizens or claimants involved: [Insert] Responsible office or institution: [Insert] Evidence standards: [Insert] Privacy safeguards: [Insert] Official engagement plan: [Insert] Expected output: [Ledger, report, recommendations, service improvement, other] What this pilot will not do: [Insert] Coordinator: [Insert] Review team: [Insert] Publication plan: [Insert] Next review date: [Insert]
A pilot without a charter easily becomes unfocused.
Form 21: Official Response Log
*Purpose: To track official responses to record requests, complaints, or pilot findings.*
Authority: [Insert] Issue: [Insert] Date contacted: [Insert] Method of contact: [Letter, email, portal, meeting, other] Records requested: [Insert] Response received: [Yes or no] Date received: [Insert] Response summary: [Insert] Records provided: [Insert] Records refused: [Insert] Reason for refusal: [Insert] Promise made: [Insert] Deadline: [Insert] Next follow-up: [Insert] Status: [Open, closed, disputed, escalated]
This log is especially useful for journalists, citizen groups, and pilot teams.
Form 22: Claimant Privacy Assessment
*Purpose: To decide how safely a case can be used.*
Claim reference: [Insert] Claimant category: [Worker, woman heir, patient, child, student, police complainant, tenant, pensioner, other] Personal exposure risk: [Low, medium, high] Retaliation risk: [Low, medium, high] Medical privacy involved: [Yes or no] Family safety risk involved: [Yes or no] Employment risk involved: [Yes or no] Legal case pending: [Yes or no] Consent obtained: [Yes or no] Recommended use: [Private only, anonymized, aggregate only, public with consent] Reviewer: [Insert] Date: [Insert]
No public accounting movement should publish sensitive cases without this kind of review.
Form 23: Remedy Tracker
*Purpose: To track whether a promised remedy actually happened.*
Issue: [Insert] Remedy requested: [Insert] Responsible authority or person: [Insert] Date requested: [Insert] Deadline: [Insert] Evidence needed to confirm remedy: [Insert] Status: [Pending, completed, delayed, rejected, disputed] If delayed, reason: [Insert] If completed, proof attached: [Insert] Citizen impact: [Insert] Next follow-up: [Insert]
Public accounting is complete not when the problem is identified but when remedy is tracked.
Form 24: Public Accounting Index Indicator Form
*Purpose: To score an institution or service against a public accounting standard.*
Domain: [Insert] Institution, district, office, or service: [Insert] Indicator: [Insert] Period assessed: [Insert] Score: [0, 1, 2, 3, or 4] Evidence supporting score: [Insert] Public record available: [Yes or no] Complaint or correction route available: [Yes or no] Official response: [Insert] Citizen impact: [Insert] Recommended action: [Insert] Next review date: [Insert]
Scoring should never be done without evidence.
Form 25: Correction of Published Finding
*Purpose: To correct a public accounting error.*
Finding reference: [Insert] Original statement: [Insert] Correction requested by: [Insert] Date correction requested: [Insert] Evidence supporting correction: [Insert] Review decision: [Accepted, partly accepted, rejected, pending] Corrected statement: [Insert] Date correction published: [Insert] Effect on recommendations: [Insert] Reviewer: [Insert]
A movement that demands accountability must correct its own errors.
Using the Forms
These forms should be adapted to local law, official procedure, language, literacy level, and safety conditions. They are not meant to replace required government forms where those exist. They are meant to help citizens prepare, organize, and preserve claims.
The forms should be translated into local languages. One-page versions should be created for common uses. Digital versions can help, but paper versions remain essential for citizens without reliable internet access.
The form should never become a barrier. If a worker, widow, patient, or poor citizen cannot complete the form, a trained helper should assist. Public accounting should reduce humiliation, not create new bureaucracy.
The Standard
One standard governs these forms: every claim should be recordable.
A form does not guarantee justice. But it gives the claim a structure. It gives the citizen a file. It gives the helper a starting point. It gives the institution less room to say the matter was never raised.
A captured order leaves citizens with stories.
A republic helps citizens create records.
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