Motor Vehicle Administration
6601 Ritchie Highway, N.E.
Glen Burnie, Maryland 21062
For more information, please call: 410-768-7000 (to speak with a customer agent).
TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov
Investigative Division Complaint Report
IS-109
(12-13)
Person Making Complaint
Your Name: ________________________________________________________________________________________Date: _______________________
Address: _______________________________________________________________________________________________________________________
City: ____________________________________________________________ State: ____________________________ Zip Code: __________________
Phone (Home): _______________________________Phone (Business):________________________________ Other (cell): _______________________
Signed: _______________________________________________________________________________________________________________________
I certify under penalty of perjury that the information contained herein is true and correct to the best of my knowledge, information, and belief.
Subject of Complaint
Subject’s Name: __________________________________________________ Phone #: _____________________________________________________
Address: _______________________________________________________________________________________________________________________
City: _____________________________________________________________ State: ________ Zip Code: ___________ Placard # _________________
Vehicles Involved: Year ___________________ Make ____________ Color ________________ Tag # _________________________________________
Year _________________Make ______________________Model _________________Color __________________ Tag # __________________________
Place of Employment for Subject (if known): _______________________________________________________________________________________
Time of day/night when subject is mostly at home or work (if know): __________________________________________________________________
Additional Comments: ___________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Additional Information On Complaint
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Use Back Of Form
MVA USE ONLY
Complaint received by: Agent/Employee: __________________________________________________________________________________________
Complaint Forwarded To: _________________________________________________Date Forwarded: ________________________________________
Action Taken (Remarks, Forwarded to, Conclusion Reached, Etc):
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Signature: _______________________________________________________ Title: _____________________________ Date: _______________________
Type of complaint: q Unlicensed Sales q Dealer Complaint q Foreign Registration q General Complaint
