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of Complaint Preliminary Statement (New York State)

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RETURN COMPLETED FORM TO:
NYS Department of State
Division of Licensing Services, Complaint Review Office
PO Box 22001
Albany, New York 12201-2001
(518) 473-2728
(submit button)
(print button)
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. The person or firm you are complaining about will receive a
copy of this document.
Have you filed a lawsuit? (please check one) YES NO
If yes, please understand that we cannot investigate matters that are the subject of a pending lawsuit.
PLEASE PR IN T O R T Y PE
NAME (LAST, FIRST, M.I., SUFFIX)
ADDRESS NUMBER AND STREET
CITY STATE ZIP+4 COUNTY
HOME PHONE BUSINESS PHONE CELL PHONE EMAIL ADDRESS
( ) ( ) ( )
PERSON AND/OR FIRM YOU ARE COMPLAINING ABOUT:
NAME (LAST, FIRST, M.I., SUFFIX) NICKNAME/BUSINESS NAME
ADDRESS NUMBER AND STREET
CITY STATE ZIP+4 COUNTY
BUSINESS PHONE CELL PHONE EMAIL ADDRESS
( ) ( )
DOS-1507 (Rev. 6/14) Page 1 of 3
Preliminary Statement
of Complaint
FOR OFFICE USE ONLY
DATE RECEIVED: ENF DISTRICT:
FILE NUMBER: ENF INVESTIGATOR:
CRU INVESTIGATOR:
CRU RECOMMENDATION:
Print FormSubmit by Email
Print Form
Submit by Email
Preliminary Statement of Complaint
TYPE OF
B
USINESS YOU
A
RE 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:
Ɣ Listing Agreement Ɣ Agency Disclosure Form Ɣ Closing Statement
Ɣ Commission Agreement Ɣ Contract of Sale Ɣ Receipts
Ɣ Real Property Management Agreement Ɣ Lease Ɣ 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
NAME AND ADDRESS OF WITNESS OR OTHER PEOPLE INVOLVED IN 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
( ) ( ) ( )
DOS-1507 (Rev. 6/14)
Page 2 of 3
Preliminary Statement of Complaint
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
( ) ( ) ( )
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.
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 (Rev. 6/14)
Page 3 of 3
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Completed 24 March 2021

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