Free CMPLAINT.P65 - Iowa

MICHAEL A. MAURO Secretary of State State of Iowa

Statement of Complaint Against a Notary Public

In order for the Secretary of State to initiate an investigation into possible misconduct of a notary public, the complaintant must complete and sign this form. Complaints should be typed or printed clearly in black or blue ink. Please state the facts briefly and clearly, and be sure to submit any documents you have to support your complaint.

Your name: ___________________________________________________________________________ Your address: _________________________________________________________________________ ____________________________________________________________________________________ Your phone number: _______________________________

Name of notary who is the subject of complaint: _____________________________________________ Address of notary (if known): ____________________________________________________________ ____________________________________________________________________________________

Date notary act occurred: ________________________________________________________________ Location where notary act occurred: _______________________________________________________ Name(s) of person(s) witnessing notary act: _________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

rev 04/07

Describe your complaint in detail below. List services provided by the notary and any fees paid for those services. Attach copies of any receipts and documents that were notarized during the transaction if possible. If you have suffered any loss or damages as a result of the alleged misconduct of the notary, please set forth the type and extent of the damage or loss. If you need more space, attach additional pages. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

State of Iowa

) ) County of __________________________ )

ss:

_____________________________________ , being of lawful age, upon his/her oath, deposes and says that he/she has read the foregoing complaint and knows the contents thereof; and that all matters herein set forth are true of his/her own knowledge. _________________________________________________
Signature of Complaintant

Subscribed and sworn to before me this _______ day of ________________________, 20 ______. _________________________________________________
Signature of Notary Public

My Commission Expires: _______________________________

SECRETARY OF STATE Notary Public Clerk Lucas Building, 1st Floor Des Moines, IA 50319 Phone: (515) 281-5204 FAX: (515) 242-5953 or (515) 281-7142 Website: www.sos.state.ia.us