Indiana Secretary of State Connie Lawson General Counsel 201 Statehouse 200 West Washington Street Indianapolis, Indiana 46204 Notary Complaint Form Personal Information of Complainant Name: Home Address: Zip Code: Home Phone Number: Business Address: Zip Code: Business Phone Number: What is the conduct that serves for the basis of the complaint? What relief are you requesting? Notary Public Information Name: Address: Zip Code: Phone: Date of expiration of notary commission: Commission Number Please attach copies of the following: Documents Notarized by the notary in question Any correspondence relating to the above I hereby verify, subject to penalties of perjury, that I have read the information contained in and attached to this complaint and that all of the information I have given is accurate and complete to the best of my knowledge and belief. SIGNATURE PRINTED NAME DATE American LegalNet, Inc. www.FormsWorkFlow.com