Fillable Form Is-109 (07-15) - Investigative Division Complaint Report printable pdf download

Motor Vehicle Administration

IS-109 (07-15)

6601 Ritchie Highway, N.E.

Glen Burnie, Maryland 21062

Investigative Division Complaint Report

Type of complaint:

Unlicensed Sales

Dealer Complaint

Foreign Registration

General Complaint

Person Making Complaint

Email: _________________________________________________________________________________________________________________________

Your Name: ________________________________________________________________________________________ Date: _______________________

Address: _______________________________________________________________________________________________________________________

City: ____________________________________________________________ State: ____________________________ Zip Code: __________________

Phone (Home): _______________________________Phone (Business):________________________________ Other (cell): _______________________

Signed: _______________________________________________________________________________________________________________________

I certify under penalty of perjury that the information contained herein is true and correct to the best of my knowledge, information, and belief.

Subject of Complaint

Subject’s Name: __________________________________________________ Phone #: _____________________________________________________

Address: _______________________________________________________________________________________________________________________

City: _____________________________________________________________ State: ________ Zip Code: ___________ Placard # _________________

Vehicles Involved: Year ___________________ Make ____________ Color ________________ Tag # _________________________________________

Year _________________Make ______________________Model _________________ Color __________________ Tag # __________________________

Place of Employment for Subject (if known): _______________________________________________________________________________________

Time of day/night when subject is mostly at home or work (if know): __________________________________________________________________

Additional Comments: ___________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________

Additional Information On Complaint

_______________________________________________________________________________________________________________________________

Use Back Of Form

MVA USE ONLY

Complaint received by: Agent/Employee: __________________________________________________________________________________________

Complaint Forwarded To: _________________________________________________Date Forwarded: ________________________________________

Action Taken (Remarks, Forwarded to, Conclusion Reached, Etc):

_______________________________________________________________________________________________________________________________

Signature: _______________________________________________________ Title: _____________________________ Date: _______________________

For more information, please call: 410-768-7000 (to speak with a customer agent).

TTY for the hearing impaired: 1-800-492-4575. Visit our website at:

Form Is-109 (07-15) - Investigative Division Complaint Report