Fillable Official Complaint Form printable pdf download

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POLICE

ILLINOIS SECRETARY OF STATE

OFFICIAL COMPLAINT

110 E. Adams

Springfield, IL 62701

FAX: 217-785-0049

***Please include all known information and attach copies of all pertinent documentation.***

Complaining Party Information

Last Name:

First Name:

Middle Initial:

Date of Birth:

________________________________________________________________________________________________________________________________

Address:

City:

State:

ZIP Code:

________________________________________________________________________________________________________________________________

Driver’s License/ID Card Number:

Home Telephone Number:

Business Telephone Number:

________________________________________________________________________________________________________________________________

Relationship to Subject of Complaint:

Subject of Complaint

Last Name:

First Name:

Middle Initial:

Date of Birth:

________________________________________________________________________________________________________________________________

Address:

City:

State:

ZIP Code:

________________________________________________________________________________________________________________________________

Driver’s License/ID Card Number:

Home Telephone Number:

Business Telephone Number:

________________________________________________________________________________________________________________________________

Place of Employment (If Vehicle Dealer, give name of Dealership):

________________________________________________________________________________________________________________________________

Address:

City:

State:

ZIP Code:

________________________________________________________________________________________________________________________________

Dealer Number:

Business Telehone Number:

Salesperson:

Vehicle Information (If Applicable)

1) Year:

Make:

Model:

Color:

________________________________________________________________________________________________________________________________

Vehicle Identification Number:

Registration Number:

________________________________________________________________________________________________________________________________

2) Year:

Make:

Model:

Color:

________________________________________________________________________________________________________________________________

Vehicle Identification Number:

Registration Number:

Please provide a narrative of your complaint, including as much detailed information as possible. (Use reverse side if needed.)

______________________________________________________________________________________________________________

I hereby affirm that the information I have provided herein is true and correct to the best of my knowledge and belief. I submit this complaint as part of

my request that the Illinois Secretary of State Police conduct a criminal investigation based on these facts. I understand that I may be called upon to

testify in criminal proceedings as a Complaining Witness.

________________________________________________

__________________________________________

Signature of Complainant

Date

________________________________________________

Full Name of Complainant (print)

Return To: Illinois Secretary of State Police, ______________________________________________________________________________

(For Office Use Only) Date Received: ____________ Reviewed By: _________________ ID Number: ______________ Date: ______________

Open Case?

Yes

Case Number: _______________________________________ Complainant Notified?