Return form by U.S. Mail, Return Receipt Requested to: State of Rhode Island Department of Administration One Capitol Hill Providence, RI 02908 (401)-222-8880 Appendix C COMPLAINT FORM COMPLAINANT INFORMATION (please print) Name: ________________________________________ Home Phone: _________________________________ Business/Cell Phone: ___________________________ E-mail: ______________________________________ Address: ___________________________________________ ___________________________________________ ___________________________________________ RESPONDENT/ NOTARY PUBLIC INFORMATION (please print) Name of Notary: ___________________________________ Address: ___________________________________________ ___________________________________________ ___________________________________________ Commission No. (if known): ________________________ Business/Cell Phone: _____________________________ E-mail: ________________________________________ NATURE OF COMPLAINT (Please include date, witnesses, and any facts deemed relevant to the alleged act) (Please attach additional sheets as necessary) OTHER QUESTIONS (Please Respond) 1. Is your signature on the subject document/s a forgery? YES _ NO _ 2. Did you personally appear before the Notary on the date shown on the notarial acknowledgment? YES _ NO _ 3. If you appeared before the Notary, did you acknowledge signing the subject document/s? YES _ NO _ 4. Do you personally know the Notary? YES _ NO _ (If Yes, please explain the nature of the relationship) __________________________________________________________________________________________________ 5. Have you referred this matter to law enforcement? YES _ NO _ IMPORTANT: 1. Please attach copies of all questioned documents to this complaint. 2. Please attach OTHER records which pertain to your complaint (examples: depositions, police reports, certified copies of documents, court records). 3. Please return this complaint form, the certified copies of questioned documents and the other documents to the address shown at the top of the page. I certify that the information in this complaint is true and correct to the best of my knowledge. Signature_____________________________________________________ Date___________________________ American LegalNet, Inc. www.FormsWorkFlow.com