Fillable Complaint Form printable pdf download

Return form by U.S. Mail, Return Receipt Requested to:

State of Rhode Island

Department of Administration

Appendix C

One Capitol Hill

Providence, RI 02908

(401)-222-8880

COMPLAINT FORM

COMPLAINANT INFORMATION (please print)

Name:

________________________________________

Home Phone: _________________________________

Address: ___________________________________________

Business/Cell Phone: ___________________________

___________________________________________

E-mail: ______________________________________

___________________________________________

RESPONDENT/ NOTARY PUBLIC INFORMATION (please print)

Name of Notary: ___________________________________

Commission No. (if known): ________________________

Address: ___________________________________________

Business/Cell Phone: _____________________________

___________________________________________

E-mail: ________________________________________

___________________________________________

NATURE OF COMPLAINT (Please include date, witnesses, and any facts deemed relevant to the alleged act)

(Please attach additional sheets as necessary)

OTHER QUESTIONS (Please Respond)

1. Is your signature on the subject document/s a forgery? YES _ NO _

2. Did you personally appear before the Notary on the date shown on the notarial acknowledgment? YES _ NO _

3. If you appeared before the Notary, did you acknowledge signing the subject document/s? YES _ NO _

4. Do you personally know the Notary? YES _ NO _ (If Yes, please explain the nature of the relationship)

__________________________________________________________________________________________________

5. Have you referred this matter to law enforcement? YES _ NO _

IMPORTANT:

1. Please attach copies of all questioned documents to this complaint.

2. Please attach OTHER records which pertain to your complaint (examples: depositions, police reports, certified

copies of documents, court records).

3. Please return this complaint form, the certified copies of questioned documents and the other documents to the

address shown at the top of the page.

I certify that the information in this complaint is true and correct to the best of my knowledge.

Signature_____________________________________________________ Date___________________________

Complaint Form