Commonwealth of Pennsylvania State Ethics Commission SEC 226 3 REVISED INSTRUCTIONS Complete all sections of the complaint form. Incomplete forms will not be processed.Give the specific name and home address of the about whom you are complaining. If you are complaining about more than one,omplaint form . may if .Provide a detailed account of the activity that is alleged to be in violation of the Ethics . The Commission222s jurisdiction extends solelytoalleged violations of the Public Official and Employee Ethics 65 Pa.C.S.247 110. Please insure that all allegations relate tospecificindividuals. If you are not sure that the Commission has jurisdiction over the conduct or individual in question, visit the Commissionwebsite or contact the State Ethics Commission.Enclose records, documents, minutes, etc., that support your allegations.. If must print.The Commission may only investigate activities within five (5) years after the occurrence of the alleged violation of the Act. IMPORTANT No public official or public employee shall discharge any official or employee or change official rank, grade or compensation, or deny a promotion or threaten to do so for filing a complaint with or providing information to the Commission or testifying in any Commission proceeding. Confidentiality The Commission will keep information, records, and proceedings relating to preliminary inquiries and investigations confidential (this includes the identity of the Complainant, unless there has been a rongful se of ct as defined below). The Commission may disclose information or records regarding a preliminary inquiry or investigation in relation to: Final orders of the Commission which become public.Hearings conducted in public, as provided by law.Appeal of Commission orders.Seeking the dvice of egal ounsel.Consulting with a law enforcement official or agency for the purpose of initiating, participating in or responding to an investigation orprosecution by the law enforcement official or agency.Testifying under oath before a governmental body or a similar body of the United States of America.The provision of discovery materials to the subject of an investigation, as required by law.When necessary or incidental to the conduct of on-going investigations or inquiries. Penalties Wrongful Use of Act Any filing a complaint with the State Ethics ommission should be aware of the following provisions of the Ethics American LegalNet, Inc. www.FormsWorkFlow.com Commonwealth of Pennsylvania State Ethics Commission SEC 226 3 REVISED FOR OFFICIAL USE ONLY ETHICS COMPLAINT completed form to: State Ethics Commission 309 Finance Building P.O. Box 11470 Harrisburg, PA 17108-1470 (717)783-16101-800-932-0936www.ethics.pa. INSTRUCTIONS 226 Please see of this form 1.Identify the you are complaining about. Name: Address: Position or Title: Work Phone Number: Home Phone Number: 2.Explain in detail why you believe the individual named above may have violated the Ethics Act. 3. Attach or make reference to any documents, materials, minutes, resolutions or other evidence which support your allegations. 4. Sworn to and subscribed before me this I swear or affirm, under penalty of perjury, that the facts set forth in this complaint are true and correct to the best of my knowledge and belief. I also swear and affirm that I have read and understand the prohibited retaliation, confidentiality, and rongful se of ct provisions on the form. Signature Print/Type your nameHome Address: Work Phone Number:Home Phone Number: American LegalNet, Inc. www.FormsWorkFlow.com