Complaint Form
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1COMPLAINT FORM
State of West Virginia
Secretary of State’s Office
West Virginia Secretary of State
Telephone: (304) 558-8000
Building 1, Suite 157-K
Toll Free: 1-877-826-2954
1900 Kanawha Blvd., East
Fax: (304) 558-8381
Charleston, WV 25305
______________________________________________________________________________________
COMPLAINT AGAINST: [ ] NOTARY PUBLIC [ ] PRIVATE INVESTIGATOR [ ] CHARITY
Today’s date:_______________________
Name(s) of person(s) making complaint: ________________________________________
Contact information (address, daytime phone #, times to call,
etc.):______________________________________________________________________
___________________________________________________________________________
Date(s) alleged event(s) occurred:______________________________________________
Person(s) allegations are against:________________________
Description of allegations (if further description is needed beyond the capacity of this
form, please attach additional pages as needed):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
_________________________________________________________________________
___________________________________________________________________________
_________________________________________________________________________
I acknowledge that all of the above information is true and accurately reflects the
matter in question, to the
best of my knowledge:
_____________________________________
STATE OF WEST VIRGINIA
COUNTY OF______________
The foregoing instrument was acknowledged before me this ________ by__ __________.
My commission expires________________
_________________________
(Notary Public)
Rev. 01/17
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