Statement of Complaint Against a Notary Public Secretary of State State of Nebraska Nebraska statutes grant the Secretary of State's Office the authority to investigate written complaints against commissioned Notaries to determine if the Notary is responsible for acts of malfeasance. Malfeasance in office means, while serving as a Notary Public, a Notary has: a) failed to follow the requirements and procedures for notarial acts provided for in any of the above situations or (b) being convicted of a felony or other crime involving fraud or dishonesty. In order to have the Secretary of State222s Office investigate alleged misconduct of a Notary, the complainant must complete this form and sign in the presence of a Notary. Please type or clearly print all facts in the spaces provided below. If additional space is needed, please attach 8 275 x 11 pages that are typed or clearly printed. Be sure to submit any documents you have to support your complaint, including the notarized document(s) that give rise to the complaint. If you are alleging that it is not your signature on a notarized document, you may be asked to provide original samples of your signature so that we may have the State Patrol conduct handwriting analysis. Sign this form and return it to: Secretary of State222s Office, Business Services Division (Notary), . If you have questions, contact the Notary staff at (402) 471-2558. Your name: Your address: Your telephone number: ( ) Name of Notary who is the subject of the complaint: Address of Notary (if known): Date notarial act occurred: Location where notarial act occurred: American LegalNet, Inc. www.FormsWorkFlow.com Name(s) of person(s) witnessing notarial act (if applicable): Please describe the events surrounding the notarial act below. Provide facts and information relative to this complaint situation only. When submitting this complaint form, you may also attach copies of relevant documentation, including the notarized document(s) that give rise to the complaint. Describe any loss or damages you sustained as a result of the alleged malfeasance on the part of the Notary. If you need more space, attach additional 8 275 x 11 sheets of paper. State of Nebraska) ) ss: County of ) I, , being of legal age, acknowledge that I have read the foregoing complaint and I affirm that all the facts stated therein are true to the best of my knowledge. Signature of Affiant filing complaint Subscribed and sworn to before me this day of , 20. Month Year Affix Notary Seal Here Signature of Notary Public American LegalNet, Inc. www.FormsWorkFlow.com