ࡱ> ?A>@ $bjbj.. 4*DDL r8>$b$dqqq$RV!9xmqxx!Zx48xrT jެsp02@.Hqs+qqq!!$" n(" PERSON BRINGING COMPLAINT Name ___________________________________________ Home Phone _________________ Work Phone _______________ Address ________________________________________________________________________ Cell Phone _______________ City ______________________________________________ State __________ Zip Code ______________________________ Email Address _____________________________________________________ PERSON OR ENTITY AGAINST WHOM COMPLAINT IS BROUGHT Please identify by name, title or position and as much additional information as possible. Name/Title ___________________________________________ Home Phone ______________ Work Phone ____________ Address _________________________________________________________________________ Cell Phone ______________ City ______________________________________________ State __________ Zip Code ______________________________ Email Address _____________________________________________________ STATEMENT OF FACTS Please provide a description of alleged violation of Title III of HAVA (Note: this description must be sufficiently detailed to apprise the Secretary of State and the official whose conduct is complained of to understand the nature and specifics of the complaint). Please provide as much of the following information as possible: The facts of the alleged violation Witnesses, if any, and contact information if you have that information Date and time when the alleged violation occurred Date and time when you became aware of the violation Location where the alleged violation occurred Other information that you think will be helpful in resolving your complaint _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(If necessary, attach additional sheets.) HEARING Do you wish to have a hearing on your complaint? (please check one) % yes % no (If no hearing is requested, the Secretary of State or designee may make a determination based on written materials.) SIGNATURE I hereby certify that the information provided above is true and correct to the best of my knowledge. Signature _____________________________________________________ Date ______________________________________ Please have a Notary Public/Attorney at Law complete the below section: Subscribed and sworn to (or affirmed) before me this _____ day of _______________, 20____ at _________________________ (Municipality, State) ______________________________________________________________ My Commission expires: ____________________ Notary Public/Attorney at Law signature and stamp or printed name Your complaint must be delivered in person or by mailed to the following address, within 60 days after the alleged violation occurred or within 60 days after you became aware of the alleged violation: Elections Division Department of the Secretary of State bj ) a b 4 5 6 : @ O y  z { Ⱦȵ֑֑֑֑֑֑֑֍܃hD{B*CJphh}R h|jdCJhD{hYvTB*CJaJphhD{hD{B*CJaJphhYvT5CJ\ *h}R5CJ\ *hYvT5CJ\hYvT h}RCJ hYvTCJh|jdhYvTCJ\hYvTCJ\aJ *h}RCJ\aJ/b 5 6 { y >]^gd}R !dh*$]^gd}R dh*$]^gd}R >]^ !dh*$]^ dh*$]^ *$]^c$$$ C mnRTa ]^gdr >]^gd}Rgd}R & F Eo]`ogd|jd ]^gd@ >]^    nPRTt J+`ajk6ǽujujjc] h|jdCJ *h}RCJh|jdh}RCJaJ h|jdh}RCJOJQJ^JaJh|jdCJaJh|jdh|jdCJaJh}RhCJaJh}RCJaJh}Rh}RCJaJ h}RCJ *h}R5CJ\h}R h@CJhYvTh|jdhD{CJaJhD{h@hD{B*CJphh@h@B*CJph"ak>?%&'$I$]gd8i ]^gd8i]gdr ]^gdr *$]^gdr ]^gdr6=?Ff  %&':>P^ 7ļĸļļxh8ih8i6CJaJh8ih}R6CJaJh8iCJaJh}Rh}RCJaJhrh}RCJaJ h8iCJh8ihrhrCJaJhrhrCJaJh}R hCJhr5CJ\h45CJ\h|jd5CJ\ h}RCJ hrCJ/ Burton M. Cross Building 111 Sewall Street (101 SHS if mailing) Augusta, fb88 04333-0101 COMPLAINT FORM Administrative Complaint Procedure under Title III of the Help America Vote Act of 2002 (HAVA) $$!$5$9$<$c$q$r$$$$$$$üh4hYvT h}RhYvTh@h}R5CJaJ h}R5h5Dth}R5h8i6CJaJh8ih}R6CJaJUh8ih8i6CJaJI$c$r$$$$$$$$$a$gd}R$a$gd8i$a$gd}R]^`gd8i 2&P1h:p8i/ =!"#h$%l@@@ }RNormalCJ_HaJmH sH tH B@B Heading 1$@&]5\DA@D Default Paragraph FontViV  Table Normal :V 44 la (k(No List FOF documentbody1CJOJQJaJo(RR@R Body Text Indent 2 \ ^\ B*ph4@4 Header  !<O"< DOC Heading35aJ@B@2@ Body Text 0*$1$aJNT@BN Block Text]^ B*ph4 @R4 Footer  !HbH @ Balloon TextCJOJQJ^JaJ  *b56 { C mn)*a k > ? % & '  2 L [ 00000000000000000 0 0 0 0 0 0000000p000p000000000000000000@0@0@0@00\e00X  {*a % &  2 L :00 Z:00:00#2jr:00 Z:00z00:00z00z00z00z00:0 0 lZ:0 0 Zz0 0z00z0 0:00 PZ:00:00 0 z00 0xeqqqqqt 6$  aI$$ $ 8@0(  B S  ? Aƻ BƻCƻZDƻ,ãEƻ,̣FƻˣGƻ,ϣHƻIƻ$ƣJƻlϣKƻlãLƻ,#MƻvNƻOƻ,PƻL)QƻdRƻD+)  B 2 2 ; A      '..@GG   9 @ K K    :*urn:schemas-microsoft-com:office:smarttagsStreet>*urn:schemas-microsoft-com:office:smarttags PostalCode;*urn:schemas-microsoft-com:office:smarttagsaddress8 *urn:schemas-microsoft-com:office:smarttagsCity9*urn:schemas-microsoft-com:office:smarttagsState=*urn:schemas-microsoft-com:office:smarttags PlaceType=*urn:schemas-microsoft-com:office:smarttags PlaceName9*urn:schemas-microsoft-com:office:smarttagsplaceB*urn:schemas-microsoft-com:office:smarttagscountry-region   d f   L ip&.?G+ . L 33333333332 K L d f L k4[ZCQ[ca0}8~X^`56.EE^E`o(. ^`hH. L^`LhH. ^`hH.   ^ `hH. U LU ^U `LhH. %%^%`hH. ^`hH. L^`LhH.hh^h`.^`56.k4}8~caCQZ          }RVXTYvT|jdyw@D{4r8i@f f )f f 4 @$@H@UnknownGz Times New Roman5Symbol3& z Arial?5 z Courier New7&  Verdana5& zaTahoma"qhFeFP P Yh24dF F  3QH?}RELECTIONS COMPLAINT FORM thomas.miscio don.wismer    Oh+'0 (4 P \ h tELECTIONS COMPLAINT FORM.LECthomas.miscioLAhomhom Normal.doti don.wismeri3n.Microsoft Word 10.0@@@-@LެP ՜.+,0 hp  NHAGNF O ELECTIONS COMPLAINT FORM Title  !"#$%&'()*+,-/012345789:;<=@Root Entry FAjެBData 1TableWordDocument4*SummaryInformation(.DocumentSummaryInformation86CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q