Form 500 - Administrative Complaint

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Form No. 500 Prescribed by the Secretary of State (10-08)
For Ohio Secretary of State Use Only
A
C
F
DMINISTRATIVE
OMPLAINT
ORM
This form may be used by any person alleging a violation of Title III
of the Help America Vote Act of 2002 (42 U.S.C. §15481-15485)
Mail or hand-deliver the signed and notarized complaint to:
Office of the Ohio Secretary of State
th
180 E. Broad Street, 15
Floor
Columbus, OH 43215
Complaint cannot be filed by fax or e-mail.
Please type or print all information.
PERSON BRINGING COMPLAINT
Name
____________________________________________________________________________________________
Street Address _______________________________________________________________________________________
City _____________________________________
County ___________________
State ___ Zip Code __________
Daytime Tel. _____________________________
E-mail address: ___________________________________________
PERSON OR ENTITY AGAINST WHOM COMPLAINT IS BROUGHT
(One person/entity per form)
Name
_ ___________________________________________________________________________________________
Street Address _______________________________________________________________________________________
City _____________________________________
County ___________________
State ___ Zip Code __________
Daytime Tel. __
____________________________
E-mail address: ___________________________________________
VIOLATION ALLEGED
Section of Title III of the Help America Vote Act of 2002 allegedly violated: ______________________________________
Date alleged violation occurred: _ __________________________
Please explain in detail the facts on which the complaint is based. If necessary, attach additional sheets, properly notarized.
Would you like the Secretary of State to conduct a hearing on the record? □ Yes □ No
I
: T
,
,
.
MPORTANT
O BE CONSIDERED
THIS COMPLAINT MUST BE PROPERLY SWORN
SIGNED AND NOTARIZED
State of Ohio, County of ______
______________
ss:
_________________________________________________
Signature of Complainant
Sworn to and subscribed in my presence by _
________________________________
, this ______ day of _________________,
___,
in the City of
__
___________________________
, County of ______________________, State of Ohio.
________________________________________________
Signature of Notary Public of the State of Ohio
My Commission expires _________________
WHOEVER COMMITS ELECTION FALSIFICATION IS GUILTY OF A FELONY OF THE FIFTH DEGREE.

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