Fillable Dsde34 English - PDF (Florida Division of Corporations)

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Dsde34 English - PDF (Florida Division of Corporations)

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DS-DE #34 (rev. 07/2016) Page 1 Rule 1S-2.025, F.A.C.
ELECTIONS FRAUD COMPLAINT
Voter Fraud Hotline Telephone number 1-877-868-3737
Under section 97.012(15), Florida Statutes, the Department of State has authority to conduct preliminary investigations into any
allegations of irregularities or fraud involving voter registration or voting, or candidate or issue petition activities. The Department
may then report its findings to the Office of Statewide Prosecution or to the State Attorney for the judicial circuit in which the
alleged violation occurred for prosecution, where warranted.
Please return the completed complaint form to: Florida Department of State, Office of the General Counsel
1
st
Floor, R.A. Gray Building
500 S. Bronough Street
Tallahassee, Florida 32399-0250
You will receive a written response from the Department of State at the end of its investigation.
PERSON BRINGING COMPLAINT
Name ____________________________________________
Day
Phone _______________
Evening
Phone ____________________
Address __________________________________________
City _______________________________________________
County ___________________________________________
State ________________
Zip
Code_____________________
E-mail Address __________________________________________________________________________________________
PERSON OR ENTITY AGAINST WHOM COMPLAINT IS BROUGHT (limit one person/entity per form)
Work
Phone ____________________________________
__________________________________________
Name of Governmental Office or
Private Entity/Office
City_____________________________________
Zip
Code____________________________________
Have you filed this complaint with the (check all that apply):
State Attorney’s Office
Yes
No
Office of Statewide Prosecution
Yes
No
Florida Department of Law Enforcement
Yes
No
Florida Elections Commission
Yes
No
Florida Commission on Ethics
Yes
No
DS-DE #34 (rev. 07/2016) Page 2 Rule 1S-2.025, F.A.C.
VIOLATION: If you believe any irregularities or fraud involving voter registration or voting, or candidate or issue
petition activities have been committed, please state the specific acts committed by the person or entity named in this
complaint:
STATEMENT OF FACTS
State in your own words exactly what happened. Please include details such as what happened, where the events or
acts happened, when they happened (including dates and times), what you were told, who spoke to you and to whom
you spoke, what you agreed or did not agree to, and who else saw or knows about what happened. Include the
names, addresses and phone numbers of relevant persons. Also, give any reasons why you feel that the person or
entity against whom you have brought this complaint knew that his or her actions were wrongful. The more specific
information that you provide to us, the better we will be able to assist you.
Check here if additional pages or documents are attached.
Signature of complainant Date Signed
Print or type name of complainant
THIS COMPLAINT IS NOT CONFIDENTIAL. ONCE IT IS FILED WITH THE DEPARTMENT OF STATE, IT BECOMES
A PUBLIC RECORD.
It is a third-degree felony for any person to knowingly and willfully make any false, fictitious, or
fraudulent statement or representation in any matter within the jurisdiction of the Department of
State. See § 817.155, Fla. Stat.
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Dsde34 English - PDF (Florida Division of Corporations)

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Completed 15 July 2020

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