State of Arizona
Election Administrative Complaint Form
KATIE HOBBS, SECRETARY OF STATE
Election Services Division
1700 W. Washington, 7
th
Fl., Phoenix, Arizona 85007
This form is to be used by anyone alleging a violation of Title III of
the Help America Vote Act (HAVA) of 2002, 52 U.S.C. § 21112.
TYPE or P
RINT ALL INFORMATION.
Please fill out this form completely, have it notarized and return it to the address above. The form must be received no
later than 60 days from the date of the alleged violation.
For more information, call Toll-free (in-state) 1-877-THE VOTE (1-877-843-8683); or 602-542-8683. TDD # 602-255-8683.
Visit www.azsos.gov for more information about HAVA and the State of Arizona HAVA Plan.
Mailing Address (include apartment # if applicable)
Daytime Phone Number (include area code)
Fax Number (include area code)
Federal Law Violations Under HAVA individuals may file a complaint if a violation: has occurred; is occurring; or is about to occur.
Date of alleged violation
Place of alleged violation
I was not allowed to
ballot
Provisions regarding
verification of new voter
registration were not followed
Provisional Ballot Not Counted
I was not able to
determine whether my
provisional ballot was
Posting Voter Information
Required voting information
was
not publicly posted in a polling
place on Election Day
Other federal law violation
If other violation, fill
out information to the
right.
Section of Title III of the Help America Vote Act of 2002 allegedly violated.
Would you like the Office of Administrative Hearings to conduct a hearing on the record?
) State of Arizona
County of ___________________
)
Subscribed and sworn (or affirmed) before me this ______ day
of ________________________, __________.
(seal)
_________________________________________________
Notary Public
Secretary of State Use Only
Do not write or staple in this space
Grievance Form Rev. 01-07-19
