Commonwealth of Pennsylvania
DEPARTMENT OF STATE 
Harrisburg

ONLINE STATEMENT OF COMPLAINT		 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 this entire form. For more information about the Department's Complaint process and jurisdiction click here.  Please state the facts briefly and clearly, and be sure to submit copies of any documents you have to support your complaint, following the forwarding instructions stated below.   Sign the form below by typing your name in the box provided and click on the submit button.

THIS FORM MUST BE FILLED OUT COMPLETELY, SIGNED AND SUBMITTED TO THE DEPARTMENT (by clicking the submit button at the bottom of this page) TO BE PROCESSED.
FAILURE TO SUPPLY COMPLETE AND ACCURATE INFORMATION MAY RESULT IN DELAYED PROCESSING OF YOUR COMPLAINT.

Complaint Form Type:

Please be aware that pursuant to Act 25 of 2009, 63 P.S. § 2205.1 if you submit a complaint anonymously the Department of State will not be able to share any information pertaining to the complaint with anyone, including you. 
A. Complainant Information B. Complainant's Attorney, if any:
Your Name (Last/First/Middle):            
 		 Name (Last/First/Middle):
Address:   Address:
City/ST/Zip:   City/ST/Zip:
County:   County:
Home Tel.: Work Tel.:  
Mobile Tel:		 Home Tel.:Work Tel.:
Mobile Tel:
I wish to remain anonymous:

C. Name and Address of Witness, if any. D. Name and Address of Second Witness, if any.
Name (Last/First/Middle):
Name (Last/First/Middle):
Address: Address:
City/ST/Zip: City/ST/Zip:
County: County:
Home Tel.: Work Tel.:
Mobile Tel:		 Home Tel.:Work Tel.:
Mobile Tel:
Is witness willing to appear at a hearing? Is witness willing to appear at a hearing?

E. Are you willing to appear at a hearing in Harrisburg if necessary?

Respondent Information

Please fill out the Business Establishment and Individual information below (secton F and G); it is required. If there is no information, then please enter 'NA' in each of the fields below (section F and G).

F. Business Establishment involved, if any. G. Individual involved, if any.
Name:   Name (Last/First/Middle):
 
Address:   Address:  
City/ST/Zip:   City/ST/Zip:  
County: County:
  Tel:     Tel:  
Proprietor: License Nbr:

H. For Notary Complaints only:

Expiration Date of Commission if known: Date of transaction for which this complaint is being filed:

I. Description of Complaint:

Please describe the facts of your complaint in detail below, in the order in which they happened.  List services provided by the licensee, registrant, certificate holder or commission holder.  Provide dates.  List fees paid for notary services, if applicable.      

Do you have any complaint-related contracts, bills, receipts, cancelled checks, correspondence, or any other documents you feel are related to your complaint?


If you answer yes to the above question, be sure to forward readable copies (not originals) of any complaint-related documents by mail to: Professional Compliance Office, Department of State, P.O. Box 2649, Harrisburg, PA 17105-2649. Please submit all supporting documents within ten days of submitting your on-line complaint so that we are able to process your complaint as quickly as possible. Due to the fact that your name will be used as your case identifier, when you mail your documents print or type your full name in the upper left-hand corner of every document that you submit. Retain the original documents and send only copies. (Additional documents cannot be attached to this form or sent electronically).

J. Resolution requested

How would you like this complaint to be resolved?  

K. Complainant's Verification and Electronic Signature

Please note that investigations by this office are confidential and privileged (See Section 5.1 of the Act of July 2, 1993 (Act 48), as amended, 63 P.S. § 2205.1). If this matter is closed without the initiation of formal disciplinary action, Act 48 prohibits this office from providing you with any additional information regarding the specific concerns which caused the file to be opened, the evidence gathered during our review and investigation, or the specific reasoning that led to this office's decision. Be sure to keep copies of all documents forwarded to the Commonwealth as confidentiality statutes may prevent us from returning these items to you. Additionally, Act 25 restricts access to this information while the file is under investigation.

PLEASE READ CAREFULLY

I verify by typing my name below 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.

Typing your name on the line below and submission of this complaint form by clicking on the submit button below shows the complainant's intent to sign this complaint form electronically in accordance with the Electronic Transactions Act, Act 69 of 1999, 73 P.S. § 2260.101 et seq.

In addition, I authorize the Pennsylvania Department of State to use this information in any way that is necessary.

 
First Complainant's Name:      eMail:
Second Complainant's Name:   eMail:

Name of Person Completing Form if other than the complainant:
Name: eMail:

Do you want a copy of this completed form to also be sent to all email addresses above?

___________________________________________________________________________________

For security purposes, we have incorporated the dialog box below. In that box you will see two words. Please print these two words in the text box below them and click the submit button.


When your online Statement of Complaint form has been submitted for processing, you will see this message at the top of your screen: Complaint Form has been submitted to the Department of State.

Please note that if more information/entries are needed prior to form submittal, validation instructions will be shown in red at the top of the form for your completion prior to submittal.

You will receive an acknowledgement letter by mail using the address information provided on your submittal. Thank you for bringing your concerns to our attention.