STATEMENT OF COMPLAINT COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF STATE Harrisburg In order for the Department of State to initiate an investigation of possible violations of the licensing, registration, certification or notary commission laws and regulations of the Commonwealth by a licensee, registrant, certificate holder or notary commission holder of the Department, the complainant must complete both sides of this form. Complaints should be typewritten or clearly printed in black or blue ink. Please state the facts briefly and clearly, and be sure to submit any documents you have to support your complaint. Sign this form and return it to the DEPARTMENT OF STATE, COMPLAINTS OFFICE, P.O. Box 2649, Harrisburg, PA 17105-2649. THIS FORM MUST BE SIGNED AND FILLED OUT COMPLETELY IN ORDER TO BE PROCESSED.TYPE OF COMPLAINT (PLEASE CHECK ONE):    NOTARY    ATHLETIC COMMISSION    CHARITY    PROFESSIONAL/OCCUPATIONAL LICENSE/CERTIFICATE/REGISTRATION    OTHER A. COMPLAINT INFORMATION LAST NAME FIRST NAME MI STREET ADDRESS (# & Name) CITY                  STATE COUNTY ZIP CODE (TEL HOME W/ Area Code) (WORK W/ Area Code) B. COMPLAINANT'S ATTORNEY, IF ANY LAST NAME                FIRST NAME    MI STREET ADDRESS (# & Name) CITY                         STATE COUNTY ZIP CODE TEL. (Include Area Code) FIRM NAME C. NAME AND ADDRESS OF WITNESS, IF ANY LAST NAME                           FIRST NAME MI STREET ADDRESS (# & Name) CITY                                           STATE COUNTY ZIP CODE TEL. (Include Area Code) If needed, is this witness willing to support your complaint by appearing at a hearing? YES NO D. NAME AND ADDRESS OF 2nd WITNESS, IF ANY LAST NAME                         FIRST NAME MI STREET ADDRESS (# & Name) CITY                                           STATE COUNTY ZIP CODE TEL. (Include Area Code) If needed, is this witness willing to support your complaint by appearing at a hearing? YES NO E. Are you willing to appear at a hearing in Harrisburg if necessary? Yes No DEFENDANT INFORMATION F. BUSINESS ESTABLISHMENT INVOLVED, IF ANY. LAST NAME                FIRST NAME    MI STREET ADDRESS (# & Name) CITY                         STATE COUNTY ZIP CODE TEL. (Include Area Code) PROPRIETOR G. INDIVIDUAL INVOLVED, IF ANY LAST NAME                FIRST NAME    MI STREET ADDRESS (# & Name) CITY                         STATE COUNTY ZIP CODE TEL. (Include Area Code) LICENSE, REGISTRATION, CERTIFICATION, COMMISSION TYPE AND NUMBER IF KNOWN H. FOR NOTARY COMPLAINTS ONLY: Expiration date of notary’s commission if known (this date should appear on the notary’s stamp, printed beneath the notary seal): Date of transaction for which this complaint is being filed: I. DESCRIPTION OF COMPLAINT: Please describe your complaint in detail below. List services provided by the licensee, registrant, certificate holder or commission holder. Provide dates. List fees paid for notary services, if applicable. Attach copies of related documents and receipts obtained during the course of the matter if possible. If you need more space, please continue on page 4 of this form and/or use additional 8 ½ x 11” sheets of paper if necessary. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ J. RESOLUTION How would you like this complaint to be resolved? Please describe your resolution. If additional space is needed, please attach 8 ½ x 11” sheets. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ K. COMPLAINANT"S VERIFICATION. I verify that the facts and statements set forth in this complaint are true and correct to the best of my knowledge, information and belief. I understand that statements in this complaint are made subject to the criminal penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities. X_____________________________________       (First Complainant's Signature)       X_____________________________________       (Second Complainant's Signature, if any)                               X_____________________________________ (Signature of person completing this form,          if other than complainant)             DATE:___________ RETURN COMPLETED FORM TO: Complaints Office Department of State P.O. Box 2649 Harrisburg, PA 17105-2649 Fax 717 705-2882 ************************************************************************************************************* L. RECORDS RELEASE (PLEASE COMPLETE IF IT APPLIES TO YOUR COMPLAINT). TO WHOM IT MAY CONCERN: THIS WILL AUTHORIZE ____________________________________________________________________________________________                                                                   (name of physician, practitioner, hospital or clinic) to release to the Department of State and its authorized representatives any pertinent medical records and copies of x-rays relating to ____________________________________________________________________________________________________________________                                                                   (patient’s name) for the purpose of investigating a complaint. X_____________________________________       (Signature) Date:       X_____________________________________       (Witness) Date: