Submit by Email Print Form Preliminary Statement of Complaint IMPORTANT: NAME (LAST, FIRST, M.I., SUFFIX) RETURN COMPLETED FORM TO: NYS Department of State Division of Licensing Services Complaint Review Office 123 William Street, 19th Floor New York, NY 10038-3804 (212) 417-5790 This document is subject to disclosure under the Freedom of Information Law. The person or firm you are complaining about will receive a copy of this complaint. PLEASE PRINT OR TYPE ADDRESS NUMBER AND STREET CITY STATE ZIP+4 COUNTY HOME TELEPHONE BUSINESS TELEPHONE EMAIL ADDRESS TYPE OF BUSINESS YOU ARE COMPLAINING ABOUT: Apartment Information Vendor/Sharing Agent Appearance Enhancement Armored Car Carrier/Guard Athlete Agent Barber Bedding Central Dispatch Facility Coin Processor Document Destruction Contractor Health Club Hearing Aid Dispenser/Business Person and/or firm you are complaining about: NAME (LAST, FIRST, M.I., SUFFIX) Home Inspector Notary Public Private Investigator, Bail Enforcement Agent & Watch, Guard or Patrol Agency Real Estate Appraiser Real Estate Broker/Sales Security & Fire Alarm Installer Security Guard Telemarketer Business Ticket Reseller Other ADDRESS NUMBER AND STREET CITY STATE ZIP+4 COUNTY TELEPHONE Name and address of other people involved in complaint: NAME (LAST, FIRST, M.I., SUFFIX) ADDRESS NUMBER AND STREET CITY STATE ZIP+4 COUNTY HOME TELEPHONE BUSINESS TELEPHONE NAME (LAST, FIRST, M.I., SUFFIX) ADDRESS NUMBER AND STREET CITY STATE ZIP+4 COUNTY HOME TELEPHONE BUSINESS TELEPHONE -OVERDOS-1507 (Rev. 12/11) American LegalNet, Inc. www.FormsWorkFlow.com Preliminary Statement of Complaint Amount of money involved in complaint: List all receipts or proof of payment: Indicate the nature of your complaint. Be exact as to facts. If you need more space, attach an additional sheet of paper: Attach copies of contracts or supporting documentation. Have you gone to: a lawyer? What action are you seeking from the Department of State? court or another agency? You may check this box in lieu of signing below. By checking this box or signing below, you acknowledge that above information is correct and that it is subject to disclosure under the Freedom of Information Law. Signature DOS-1507 (Rev. 12/11) Date American LegalNet, Inc. www.FormsWorkFlow.com