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Complaint Form. This is a North Carolina form and can be use in Notary Secretary Of State.
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Tags: Complaint Form, North Carolina Secretary Of State, Notary
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STATE OF NORTH CAROLINA
DEPARTMENT OF THE SECRETARY OF STATE
Certification and Filing Division
Office of Notary Investigations and Enforcement
P.O. BOX 29626
RALEIGH, NC 27626-0622
PHONE: 919-807-2105 FAX: 919-807-2210
E-MAIL: Notary@sosnc.com WEBSITE ADDRESS: WWW.SOSNC.COM
ELAINE F. MARSHALL
SECRETARY OF STATE
COMPLAINT FORM
The Department has the authority to investigate complaints against any North Carolina Notary when there is an allegation or
appearance of violation of Chapter 10B of the North Carolina General Statutes, any rule adopted or any order issued pursuant to this
Chapter.
Instructions: Please provide detailed information, be specific and compose clear, concise answers. Please furnish copies of any
documents or other materials relating to this complaint. If additional space is needed attach separate sheets and reference the item.
Please type or print clearly.
COMPLAINANT INFORMATION
USE TAB OR ARROW KEY
FULL NAME:
First
Middle
Last
DATE OF
BIRTH:
MM/DD/YYYY
ADDRESS:
STATE:
CITY:
ZIP:
BUSINESS PHONE:
HOME
PHONE:
FAX NUMBER:
CELL PHONE:
E-MAIL:
INFORMATION ABOUT THE NOTARY WHICH YOU ARE FILING A COMPLAINT AGAINST
If more space is needed please attach additional pages and reference the item as “Notary Information”
Notary Name
NAME OF NOTARY’S
EMPLOYER:
Title/Position
Notary Address
Phone No.
DBA OR OTHER
NAMES IT USES, IF
ANY:
ADDRESS OF
ORGANIZATION:
CITY:
STATE:
PHONE:
CELL PHONE:
FAX NUMBER:
ZIP:
E-MAIL:
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(If you need more space attach additional sheets and reference the item number.)
1.
Describe your complaint. Be Specific.
2. Describe documents in your possession that relate to your complaint. Please attach copies of all relevant materials to
this complaint.
3. Have you contacted any other agency regarding your complaint?
address, phone number and contact person.
Agency
Address
If so, please provide the name of the agency,
Telephone
Contact Person
4. Have you contacted the person or organization against which you have a complaint? If so, please provide us with the
name of the individual you spoke with and tell us their response. (Please attach copies of any correspondence along with
other documents exchanged between you and this entity.)
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5. Have you contacted a private attorney regarding this matter? If so, please include the attorney’s name, address and
phone number.
Attorney Name
Address
Telephone
6. Is court action pending? If so, please furnish the name and location of the court as well as the name, title, and index
number of the proceeding. (Please provide copies of any relevant court documents.)
7. Are you aware of any person other than yourself that might have or had a similar experience with this notary or who
might be able to provide additional information that would be helpful? If so, please provide name, address and phone
number, and explain their role below.
Name
Address
Telephone
8. Are you aware of any other names, principles, associates or organizations affiliated with the subject of your complaint
that might be able to contribute additional details regarding this matter? If so, please include addresses and phone
numbers.
Name of Person or Organization
Address
Telephone
Contact Person for Organization
Please be advised that the North Carolina Department of the Secretary of State Notary Public Section has authority over
matters that relate to N.C.G.S. § 10B for the purpose of protecting the public against fraud and forgery by commissioning
and regulating notaries public. The function of this section is to investigate accusations of official misconduct on the part
of a notary. This agency does not become involved in domestic disputes. This section does not act as your personal
attorney nor can we recover money or property for you. If you have questions about your legal rights and responsibilities
please consult a private attorney. Please be aware that most information maintained by this Department is public record as
a matter of law. By signing below you acknowledge that you are willing to appear in court and testify in this matter if
necessary.
Mail the completed form and all documentation to: NC Department of the Secretary of State, Notary
Enforcement Section, P.O. Box 29626, Raleigh, NC 27626-0622
Signature
Printed Name
9/17/2008
Date
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