Fillable Dsde121 English PDF (Florida Division of Corporations)

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Dsde121 English PDF (Florida Division of Corporations)

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Please return to: Florida Department of State
Division of Elections
R.A. Gray Building
500 S. Bronough Street
Tallahassee, Florida 32399-0250
Once This Complaint Is Filed With The Division Of Elections, It Becomes A Public Record And Is Available
To The Public And Media Upon Request Unless A Specific Statutory Exemption Applies.
FORM FOR COMPLAINT AGAINST
THIRD-PARTY VOTER REGISTRATION ORGANIZATION
You will receive a written response from the Division of Elections at the end of its investigation. The
Division may report its findings to the Office of Statewide Prosecution or to the State Attorney for the
applicable judicial circuit if probable cause is found that a criminal violation also occurred.
PERSON BRINGING COMPLAINT
Name ____________________________________________
(First) (Middle or Initial) (Last)
Day
Phone _______________
Evening
Phone ____________________
Address __________________________________________
City _______________________________________________
County ___________________________________________
State ________________
Zip
Code_____________________
E-mail Address (optional)__________________________________________________________________________________
THIRD-PARTY VOTER REGISTRATION ORGANIZATION (PERSON, ENTITY or ORGANIZATION AGAINST
WHOM COMPLAINT IS BROUGHT) (limit one person/entity per form)
Name _____________________________________________________
Phone ____________________________________
Address__________________________________________________________
City______________________________________
County ______________________________________________State________
Zip Code_________________________________
STATEMENT OF FACTS AND CIRCUMSTANCES AS BASIS FOR ALLEGED VIOLATION. Please respond to
the following questions to the best of your knowledge.
1. To whom did you speak (include names of persons or at a minimum the name of the third-party voter registration
organization?
______________________________________________________________________________________________________
2. From whom and where did you receive your voter registration application (date and location including address
and/or event)?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
DS-DE 121 (eff. 06/2011) Page 1 of 2 Rule 1S-2.042, F.A.C.
FORM FOR COMPLAINT AGAINST
THIRD-PARTY VOTER REGISTRATION ORGANIZATION – PAGE 2
3. When did you sign your voter registration application?
______________________________________________________________________________________________________
4. To whom did you submit your voter registration application?
______________________________________________________________________________________________________
5. How did you submit your voter registration application (by hand-delivery, by mail, etc.)
______________________________________________________________________________________________________
6. When did you submit your voter registration application (include time and date)?
______________________________________________________________________________________________________
7. How and when did you check on your voter registration status and determine that your name did not appear on the
voter registration rolls?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
8. Please include other relevant details (The more specific information that you provide to us, the better we are able to
assist you. Attach additional pages as necessary.)
It is a second degree misdemeanor, punishable as provided in s. 775.082 and s. 775.083, Florida Statutes, for any
person to knowingly make a false official statement. (s. 837.06, Florida Statutes)
Check here is additional pages or
documents are attached.
Signature of complainant Date Signed
Print or type name of complainant
DS-DE 121 (eff. 06/2011) Page 2 of 2 Rule 1S-2.042, F.A.C.
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Dsde121 English PDF (Florida Division of Corporations)

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Completed 30 July 2020

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