Statement Of Complaint - Commonwealth Of Pennsylvania Department Of State
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1
2
3STATEMENT 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 and sign this form. Failure to supply complete and accurate information
may result in delayed processing of your complaint. Please be aware that pursuant to Act 25 of 2009, 63 P.S. §2205.1, if you
submit a complaint anonymously, the Department will not be able to share any information pertaining to the complaint with anyone,
including you. Please return this completed form to: DEPARTMENT OF STATE, PROFESSIONAL COMPLIANCE OFFICE,
2601 NORTH THIRD STREET, P.O. BOX 2649, HARRISBURG, PA 17105-2649.
TYPE OF COMPLAINT:
PROFESSIONAL/OCCUPATIONAL LICENSE/CERTIFICATE/REGISTRATION
NOTARY
OTHER
⃞
⃞
⃞
A. COMPLAINANT INFORMATION
B. COMPLAINANT’S ATTORNEY, IF ANY
LAST NAME
FIRST
MIDDLE INITIAL
LAST NAME
FIRST
MIDDLE INITIAL
STREET ADDRESS (Number and Name)
STREET ADDRESS (Number and Name)
CITY
COUNTY
STATE
ZIP CODE
CITY
COUNTY
STATE
ZIP CODE
TEL. (Include Area Code) (HOME)
(WORK)
TEL. (Include Area Code)
FIRM NAME
C. NAME AND ADDRESS OF WITNESS, IF ANY
D. NAME AND ADDRESS OF SECOND WITNESS, IF ANY
LAST NAME
FIRST
MIDDLE INITIAL
LAST NAME
FIRST
MIDDLE INITIAL
STREET ADDRESS (Number and Name)
STREET ADDRESS (Number and Name)
CITY
COUNTY
STATE
ZIP CODE
CITY
COUNTY
STATE
ZIP CODE
TEL. (Include Area Code)
If needed, is this witness willing to
TEL. (Include Area Code)
If needed, is this witness willing to
support your complaint by appearing at
support your complaint by appearing
a hearing?
Y ES
NO
at a hearing?
Y ES
NO
⃞
⃞
⃞
⃞
NOTE: If additional witnesses are available, list names, addresses, and other pertinent data in a manner similar to above on 8½ x 11” paper.
E. ARE YOU WILLING TO APPEAR AT A HEARING IN HARRISBURG IF NECESSARY?
YES
NO
DEFENDANT INFORMATION
F. BUSINESS ESTABLISHMENT INVOLVED, IF ANY
G. INDIVIDUAL INVOLVED, IF ANY
LAST NAME
FIRST
MIDDLE INITIAL
LAST NAME
FIRST
MIDDLE INITIAL
STREET ADDRESS (Number and Name)
STREET ADDRESS (Number and Name)
CITY
COUNTY
STATE
ZIP CODE
CITY
COUNTY
STATE
ZIP CODE
TEL. (Include Area Code)
PROPRIETOR
TEL. (Include Area Code)
LICENSE/REGISTRATION/
CERTIFICATE/COMMISSION
TYPE AND NUMBER IF KNOWN
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