Name of Respondent:
Name of Complainant:
Although my signature on this document does not constitute an admission of guilt, I do acknowledge that the complainant perceived my actions as being offensive. My signature on this form is my agreement that I will cease-and-desist the actions that are perceived as being offensive.
Signature of respondent Date
I am satisfied my complaint has been acknowledged and that actions taken by the respondent are satisfactory to me.
Signature of complainant Date