Fillable AFFIDAVIT OF COMPLAINT (State of Connecticut/Department of Administrative Services)

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AFFIDAVIT OF COMPLAINT (State of Connecticut/Department of Administrative Services)

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BROWSE STATE OF CONNECTICUT/DEPARTMENT OF ADMINISTRATIVE SERVICES (CT) FORMS

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AFFIDAVIT OF COMPLAINT
STATE ELECTIONS ENFORCEMENT COMMISSION
Revised July 2012
This Space For Official Use Only
Page 1 of 6
COMPLAINANT’S STREET ADDRESS
Address
City State Zip Code
Home Work Cell
COMPLAINANT’S TELEPHONE NUMBER
COMPLAINANT’S EMAIL ADDRESS
COMPLAINANT’S NAME
First Name MI Last Name Suffix
Please complete this form to the fullest extent possible.
The following sections are required and must be completed in full:
I. Identity of Complainant(s)—page 1 | III. Violation(s) Alleged—page 3 | VI. Certification—page 6
COMPLAINANT’S STREET ADDRESS
Address
City State Zip Code
Home Work Cell
COMPLAINANT’S TELEPHONE NUMBER
COMPLAINANT’S EMAIL ADDRESS
COMPLAINANT’S NAME
First Name MI Last Name Suffix
COMPLAINANT’S STREET ADDRESS
Address
City State Zip Code
Home Work Cell
COMPLAINANT’S TELEPHONE NUMBER
COMPLAINANT’S EMAIL ADDRESS
COMPLAINANT’S NAME
First Name MI Last Name Suffix
I. IDENTITY OF COMPLAINANT(S)
AFFIDAVIT OF COMPLAINT
STATE ELECTIONS ENFORCEMENT COMMISSION
Revised July 2012
Page 2 of 6
Number of Pages
Copy and attach page(s) for additional respondents if necessary.
Please check “See attached Additional Respondent List” and list the number of pages.
See attached ________ Additional Respondent List pages
RESPONDENT’S STREET ADDRESS (If known)
Address
City State Zip Code
Home Work Cell
RESPONDENT’S TELEPHONE NUMBER (If known)
RESPONDENT’S EMAIL ADDRESS (If known)
RESPONDENT’S NAME (If known; otherwise write “unknown”)
First Name MI Last Name Suffix
STATUTE(S) VIOLATED (If known)
§
RESPONDENT’S STREET ADDRESS (If known)
Address
City State Zip Code
Home Work Cell
RESPONDENT’S TELEPHONE NUMBER (If known)
RESPONDENT’S EMAIL ADDRESS (If known)
RESPONDENT’S NAME (If known, otherwise write “unknown”)
First Name MI Last Name Suffix
STATUTE(S) VIOLATED (If known)
§
RESPONDENT’S STREET ADDRESS (If known)
Address
City State Zip Code
Home Work Cell
RESPONDENT’S TELEPHONE NUMBER (If known)
RESPONDENT’S EMAIL ADDRESS (If known)
RESPONDENT’S NAME (If known, otherwise write “unknown”)
First Name MI Last Name Suffix
STATUTE(S) VIOLATED (If known)
§
II. IDENTITY OF RESPONDENT(S)
AFFIDAVIT OF COMPLAINT
STATE ELECTIONS ENFORCEMENT COMMISSION
Revised July 2012
Page 3 of 6
Please be as specific as possible with regard to time, place, and the individual(s) taking actions or failing to act, and in de-
scribing their actions as well as other witnesses or persons involved. If applicable, please clearly refer to the names of identi-
fied respondents, witnesses, and attached evidence (e.g., See Evidentiary Attachment B.). If you have identified more than
one respondent, please identify which respondent is alleged to have committed which action and which specific alleged
violation of the statutes.
If you are unable to provide the specific identity of any witnesses in the following “Witnesses” section, please provide as
much identifying information as possible in the below “Concise Statement of Facts.”
The respondent(s) allegedly violated the law as follows:
DATE(S) OF ALLEGED VIOLATION(S) (If known)
CONCISE STATEMENT OF FACTS
Number of Pages
Use attached page(s) for additional statement of facts if necessary.
Please check “See attached Additional Statement of Facts” and list the number of pages.
See attached ________ Additional Statement of Facts pages
III. VIOLATION(S) ALLEGED
AFFIDAVIT OF COMPLAINT
STATE ELECTIONS ENFORCEMENT COMMISSION
Revised July 2012
CONCISE STATEMENT OF FACTS continued
ADDITIONAL STATEMENT OF FACTS
Page ______ of ______
AFFIDAVIT OF COMPLAINT
STATE ELECTIONS ENFORCEMENT COMMISSION
Revised July 2012
Page 4 of 6
Number of Pages
Copy and attach page(s) for additional witnesses if necessary.
Please check “See attached Additional Witness List” and list the number of pages.
See attached ________ Additional Witness List pages
WITNESS’S STREET ADDRESS (If known)
Address
City State Zip Code
Home Work Cell
WITNESS’S TELEPHONE NUMBER (If known)
WITNESS’S EMAIL ADDRESS (If known)
WITNESS’S NAME (If known)
First Name MI Last Name Suffix
WITNESS’S STREET ADDRESS (If known)
Address
City State Zip Code
Home Work Cell
WITNESS’S TELEPHONE NUMBER (If known)
WITNESS’S EMAIL ADDRESS (If known)
WITNESS’S NAME (If known)
First Name MI Last Name Suffix
WITNESS’S STREET ADDRESS (If known)
Address
City State Zip Code
Home Work Cell
WITNESS’S TELEPHONE NUMBER (If known)
WITNESS’S EMAIL ADDRESS (If known)
WITNESS’S NAME (If known)
First Name MI Last Name Suffix
IV. WITNESSES
AFFIDAVIT OF COMPLAINT
STATE ELECTIONS ENFORCEMENT COMMISSION
Revised July 2012
Page 5 of 6
ATTACHED DOCUMENTARY OR REAL EVIDENCE
Author
How Acquired
Date of Publication
EVIDENTIARY ATTACHMENT
Title
Number of Pages
Copy and attach page(s) for additional evidence if necessary.
Please check “See attached Additional Evidence List” and list the number of pages.
See attached ________ Additional Evidence List pages
Please identify each attachment by number of pages, title, author and date if applicable. Records not identified as
attachments shall not be considered a part of the complaint. Please do not provide a website listing as evidence, as this
information is subject to change. If you wish to provide Internet or other video or audio communications as evidence,
please provide a printed or electronic copy, as appropriate, and list it as an exhibit.
Under “How Acquired” please identify your source for the evidence (e.g., delivery from an individual, Internet website,
public flyer location). If the source is an individual, please identify the individual in the witness list. If the source is a
publication, such as a newspaper, please identify the publication’s name and date of the publication.
Number of Pages
Date Acquired
Author
How Acquired
Date of Publication
EVIDENTIARY ATTACHMENT
Title
Number of Pages
Date Acquired
Author
How Acquired
Date of Publication
EVIDENTIARY ATTACHMENT
Title
Number of Pages
Date Acquired
Author
How Acquired
Date of Publication
EVIDENTIARY ATTACHMENT
Title
Number of Pages
Date Acquired
V. EVIDENCE
AFFIDAVIT OF COMPLAINT
STATE ELECTIONS ENFORCEMENT COMMISSION
Revised July 2012
Page 6 of 6
COMPLAINANT’S SIGNATURE DATE (mm/dd/yyyy)
I solemnly swear (or affirm) that the above statement is true and accurate
to the best of my knowledge and belief.
SIGNATURE OF PERSON ADMINISTERING THE OATH
Seal
Sworn and subscribed before me on this day of , 20
NAME OF PERSON ADMINISTERING THE OATH (Please Print)
TITLE OF PERSON ADMINISTERING THE OATH
Note: This oath may be administered by anyone authorized by Section 1-24 of the Connecticut General Statutes, which includes: notaries public; justices of the peace;
town clerks and assistant town clerks; judges and clerks of any court; and attorneys who are Commissioners of the Superior Court of Connecticut.
CERTIFICATION
1) Each Complainant must sign a separate page and each signature must be separately certified. This
complaint will not be considered filed without the name, address, and original certified signature of
at least one Complainant. Mail or hand-deliver this complaint to:
State Elections Enforcement Commission
55 Farmington Ave
Hartford, CT 06105
2) Once filed, this complaint may not be withdrawn by the Complainant(s) except by a vote of the State
Elections Enforcement Commission.
3) I am aware that criminal penalties may be imposed upon any Complainant who, under penalty of
false statement, knowingly files a false complaint.
4) The State Elections Enforcement Commission’s investigation of a complaint is confidential unless
and until the State Elections Enforcement Commission votes to authorize an investigation of a
complaint. Until such a vote, neither the Commission nor its staff will release or confirm any
information about the complaint except upon written request of a treasurer, deputy treasurer,
chairperson or candidate affiliated with a committee that is the subject of the complaint or
preliminary investigation.
Guides to the elections laws are available at http://www.ct.gov/seec
Connecticut General Statutes are available at http://www.cga.ct.gov
VI. CERTIFICATION
THIS PAGE INTENTIONALLY LEFT BLANK
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AFFIDAVIT OF COMPLAINT (State of ConnecticutDepartment of Administrative Services)

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Completed 2 August 2021

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