Fillable ary Statement of Complaint Prelimin (New York State)

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ary Statement of Complaint Prelimin (New York State)

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FOR OFFICE USE ONLY
FILE NUMBER:
RETURN COMPLETED FORM TO:
New York State
Department of State
Division of Licensing Services
Complaint Review Office
P.O. Box 22001
Albany, NY 12201-2001
(518) 473-2728
www.dos.ny.gov
Prelimin
ary Statement of Complaint
IMPORTANT: The Department of State represents the interests of the people of the State of New York, which interests may differ
from your own. We cannot provide you with legal advice and cannot seek damages on your behalf. You should consult with a private
attorney for advice on these matters. If you believe a licensee has committed a crime, you should contact law enforcement. This
document is subject to disclosure under the Freedom of Information Law.
Have you filed a lawsuit regarding this complaint? (please check one) YES NO
If yes, please be advised that the Department may decline to investigate pending matters that are subject of a lawsuit until
those issues have been resolved.
Are you licensed by the Department of State? YES NO
What type of license do you have?
PLEASE PR IN T O R T Y PE
NAME (LAST, FIRST, M.I., SUFFIX)
EMAIL ADDRESS – THE DIVISION OF LICENSING SERVICES WILL PRIMARILY CONTACT YOU REGUARDING THIS COMPLAINT BY EMAIL.
ADDRESS NUMBER AND STREET (PERSONAL OR BUSINESS)
CITY STATE ZIP+4 COUNTY
PRIMARY PHONE BUSINESS PHONE CELL PHONE
( ) ( ) ( )
PERSON AND/OR FIRM YOU ARE COMPLAINING ABOUT:
NAME (LAST, FIRST, M.I., SUFFIX) NICKNAME/BUSINESS NAME
ADDRESS NUMBER AND STREET (PERSONAL OR BUSINESS)
CITY STATE ZIP+4 COUNTY
BUSINESS PHONE CELL PHONE EMAIL ADDRESS
( ) ( )
LICENSE NUMBER, IF KNOWN
DOS-1507-f (Rev. 06/19)
Preliminary Statement of Complaint
TYPE OF BUSINESS YOU ARE COMPLAINING ABOUT:
Real Estate Broker/Sales - Attach any available documents and/or records relevant to the transaction(s) in question, including but
not limited to, the following:
● Listing Agreement ● Agency Disclosure Form ● Closing Statement
● Commission Agreement ● Contract of Sale ● Receipts
● Real Property Management Agreement ● Lease ● Rental Applications
Real Estate Appraiser – Attach appraisal reports(s) and proof of payment.
Private Investigator – Attach advanced statement of service/contract, proof of payment, and investigative reports.
Notary Public – Attach notarized document(s) in question.
Home Inspector – Attach inspection report and proof of payment.
Security Guard
Hearing Aid Dispenser/Business – Attach contract and/or receipt and proof of payment.
Security and Fire Alarm Installer – Attach contract and/or invoice and proof of payment.
Ticket Reseller – Attach complete copies of invoices, receipts, and proof of payment.
Apartment Information Vendor/Sharing Agent – Attach contract, escrow agreement, and proof of payment.
Nails, Beauty and Barber – You may file this complaint at “One-Stop E-Licensing” at: https://aca.licensecenter.ny.gov/aca/
Attach any and all available documents relevant to the transaction(s) in question for the following:
Armored Car Carrier/Guard Coin Processor
Athlete Agent Document Destruction Contractor
Bedding Health Club
Central Dispatch Facility Telemarketer Business
Other: Please Specify
DOS-1507-f (Rev. 06/19)
Preliminary Statement of Complaint
Witness #1
NAME (LAST, FIRST, M.I., SUFFIX)
ADDRESS NUMBER AND STREET
CITY STATE ZIP+4 COUNTY
HOME PHONE BUSINESS PHONE CELL PHONE EMAIL ADDRESS
( ) ( ) ( )
Witness #2
NAME (LAST, FIRST, M.I., SUFFIX)
ADDRESS NUMBER AND STREET
CITY STATE ZIP+4 COUNTY
HOME PHONE BUSINESS PHONE CELL PHONE EMAIL ADDRESS
( ) ( ) ( )
Witness #3
NAME (LAST, FIRST, M.I., SUFFIX)
ADDRESS NUMBER AND STREET
CITY STATE ZIP+4 COUNTY
HOME PHONE BUSINESS PHONE CELL PHONE EMAIL ADDRESS
( ) ( ) ( )
Witness #4
NAME (LAST, FIRST, M.I., SUFFIX)
ADDRESS NUMBER AND STREET
CITY STATE ZIP+4 COUNTY
HOME PHONE BUSINESS PHONE CELL PHONE EMAIL ADDRESS
( ) ( ) ( )
DOS-1507-f (Rev. 06/19)
NAME AND ADDRESS OF WITNESS OR OTHER PEOPLE INVOLVED IN COMPLAINT:
Preliminary Statement of Complaint
Description of Complaint
PERSON AND/OR FIRM FILING COMPLAINT NAME (LAST, FIRST, M.I., SUFFIX)
PERSON AND/OR FIRM YOU ARE FILING A COMPLAINT ABOUT: NAME (LAST, FIRST, M.I., SUFFIX)
AMOUNT OF MONEY INVOLVED IN COMPLAINT:
INDICATE THE NATURE OF YOUR COMPLAINT. BE EXACT WITH FACTS. IF YOU NEED
MORE SPACE, ATTACH AN ADDITIONAL SHEET OF PAPER. ATTACH ALL SUPPORTING
DOCUMENTS RELEVANT TO TRANSACTIONS DESCRIBED. ATTACH ANY
CORRESPONDENCE, INCLUDING EMAIL, WITH THE PARTY YOU ARE COMPLAINING
ABOUT. PLEASE REFRAIN FROM USING ANY PERSONALLY IDENTIFIABLE
INFORMATION SUCH AS HOME ADDRESSES, EMAIL ADDRESSES AND TELEPHONE
NUMBERS. THE PERSON OR FIRM YOU ARE COMPLAINING ABOUT WILL RECEIVE A
COPY OF THIS DOCUMENT.
You may check this box in lieu of signing below. By checking this box or signing below, you acknowledge that the
above information is correct and that it is subject to disclosure under the Freedom of Information Law.
Signature Date
DOS-1507-f (Rev. 06/19)
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ary Statement of Complaint Prelimin (New York State)

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Completed 8 August 2021

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