PAUL D. PATE Secretary of State State of Iowa Statement of Complaint Against a Notary Public or a Notarial Officer In order for the Secretary of State to initiate an investigation this form shall be completed and signed. Complaints shall be typed or printed legibly in black or blue ink. Complainant Information: Name: Address: Email (optional): Complaint Information: Name of Notary: Notary's Address (if known): Notary's Phone Number (if known): Notary's Employer (if known): Date of incident: Location of incident: Phone Number: Please clearly state the facts and provide information concerning the nature of your complaint including services provided, fees paid, names and contact information of witnesses, and any losses or damages. Also submit any documentation in support of your complaint. If more space is needed, attach additional pages. Number of additional pages attached: Complainant's Signature: Date Submitted: SECRETARY OF STATE Notary Division Lucas Building, 1st Floor Des Moines, IA 50319 Phone: (515) 281-5204 Fax: (515) 242-5953 Website: sos.iowa.gov American LegalNet, Inc. www.FormsWorkFlow.com