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AFFIDAVIT OF COMPLAINT
STATE ELECTIONS ENFORCEMENT COMMISSION
Revised July 2012
This Space For Official Use Only

Please complete this form to the fullest extent possible.

The following sections are required and must be completed in full:
I. Identity of Complainant(s)—page 1 | III. Violation(s) Alleged—page 3 | VI. Certification—page 6

I. IDENTITY OF COMPLAINANT(S)
COMPLAINANT’S NAME
First Name MI Last Name Suffix

COMPLAINANT’S STREET ADDRESS

Address

City State Zip Code

COMPLAINANT’S TELEPHONE NUMBER

Home Work Cell

COMPLAINANT’S EMAIL ADDRESS

COMPLAINANT’S NAME
First Name MI Last Name Suffix

COMPLAINANT’S STREET ADDRESS

Address

City State Zip Code

COMPLAINANT’S TELEPHONE NUMBER

Home Work Cell

COMPLAINANT’S EMAIL ADDRESS

COMPLAINANT’S NAME
First Name MI Last Name Suffix

COMPLAINANT’S STREET ADDRESS

Address

City State Zip Code

COMPLAINANT’S TELEPHONE NUMBER

Home Work Cell

COMPLAINANT’S EMAIL ADDRESS

AFFIDAVIT OF COMPLAINT Page 2 of 6
STATE ELECTIONS ENFORCEMENT COMMISSION
Revised July 2012

II. IDENTITY OF RESPONDENT(S)

RESPONDENT’S NAME (If known; otherwise write “unknown”)
First Name MI Last Name Suffix

RESPONDENT’S STREET ADDRESS (If known)

Address

City State Zip Code

RESPONDENT’S TELEPHONE NUMBER (If known)

Home Work Cell

RESPONDENT’S EMAIL ADDRESS (If known) STATUTE(S) VIOLATED (If known)

§
RESPONDENT’S NAME (If known, otherwise write “unknown”)
First Name MI Last Name Suffix

RESPONDENT’S STREET ADDRESS (If known)

Address

City State Zip Code

RESPONDENT’S TELEPHONE NUMBER (If known)

Home Work Cell

RESPONDENT’S EMAIL ADDRESS (If known) STATUTE(S) VIOLATED (If known)

§
RESPONDENT’S NAME (If known, otherwise write “unknown”)
First Name MI Last Name Suffix

RESPONDENT’S STREET ADDRESS (If known)

Address

City State Zip Code

RESPONDENT’S TELEPHONE NUMBER (If known)

Home Work Cell

RESPONDENT’S EMAIL ADDRESS (If known) STATUTE(S) VIOLATED (If known)

Copy and attach page(s) for additional respondents if necessary.

Please check “See attached Additional Respondent List” and list the number of pages.
See attached ________ Additional Respondent List pages
Number of Pages
AFFIDAVIT OF COMPLAINT Page 3 of 6
STATE ELECTIONS ENFORCEMENT COMMISSION
Revised July 2012

III. VIOLATION(S) ALLEGED

DATE(S) OF ALLEGED VIOLATION(S) (If known)

CONCISE STATEMENT OF FACTS

Please be as specific as possible with regard to time, place, and the individual(s) taking actions or failing to act, and in de-
scribing their actions as well as other witnesses or persons involved. If applicable, please clearly refer to the names of identi-
fied respondents, witnesses, and attached evidence (e.g., See Evidentiary Attachment B.). If you have identified more than
one respondent, please identify which respondent is alleged to have committed which action and which specific alleged
violation of the statutes.
If you are unable to provide the specific identity of any witnesses in the following “Witnesses” section, please provide as
much identifying information as possible in the below “Concise Statement of Facts.”
The respondent(s) allegedly violated the law as follows:

Use attached page(s) for additional statement of facts if necessary.

Please check “See attached Additional Statement of Facts” and list the number of pages.

See attached ________ Additional Statement of Facts pages

Number of Pages
AFFIDAVIT OF COMPLAINT
STATE ELECTIONS ENFORCEMENT COMMISSION
Revised July 2012

ADDITIONAL STATEMENT OF FACTS

Page ______ of ______

CONCISE STATEMENT OF FACTS continued

AFFIDAVIT OF COMPLAINT Page 4 of 6
STATE ELECTIONS ENFORCEMENT COMMISSION
Revised July 2012

IV. WITNESSES
WITNESS’S NAME (If known)
First Name MI Last Name Suffix

WITNESS’S STREET ADDRESS (If known)

Address

City State Zip Code

WITNESS’S TELEPHONE NUMBER (If known)

Home Work Cell

WITNESS’S EMAIL ADDRESS (If known)

WITNESS’S NAME (If known)

First Name MI Last Name Suffix

WITNESS’S STREET ADDRESS (If known)

Address

City State Zip Code

WITNESS’S TELEPHONE NUMBER (If known)

Home Work Cell

WITNESS’S EMAIL ADDRESS (If known)

WITNESS’S NAME (If known)

First Name MI Last Name Suffix

WITNESS’S STREET ADDRESS (If known)

Address

City State Zip Code

WITNESS’S TELEPHONE NUMBER (If known)

Home Work Cell

WITNESS’S EMAIL ADDRESS (If known)

Copy and attach page(s) for additional witnesses if necessary.

Please check “See attached Additional Witness List” and list the number of pages.
See attached ________ Additional Witness List pages
Number of Pages
 AFFIDAVIT OF COMPLAINT Page 5 of 6
STATE ELECTIONS ENFORCEMENT COMMISSION
Revised July 2012

V. EVIDENCE
ATTACHED DOCUMENTARY OR REAL EVIDENCE

Please identify each attachment by number of pages, title, author and date if applicable. Records not identified as
attachments shall not be considered a part of the complaint. Please do not provide a website listing as evidence, as this
information is subject to change. If you wish to provide Internet or other video or audio communications as evidence,
please provide a printed or electronic copy, as appropriate, and list it as an exhibit.
Under “How Acquired” please identify your source for the evidence (e.g., delivery from an individual, Internet website,
public flyer location). If the source is an individual, please identify the individual in the witness list. If the source is a
publication, such as a newspaper, please identify the publication’s name and date of the publication.

EVIDENTIARY ATTACHMENT
Title Number of Pages

Author Date of Publication

How Acquired Date Acquired

EVIDENTIARY ATTACHMENT
Title Number of Pages

Author Date of Publication

How Acquired Date Acquired

EVIDENTIARY ATTACHMENT
Title Number of Pages

Author Date of Publication

How Acquired Date Acquired

EVIDENTIARY ATTACHMENT
Title Number of Pages

Author Date of Publication

How Acquired Date Acquired

Copy and attach page(s) for additional evidence if necessary.

Please check “See attached Additional Evidence List” and list the number of pages.

See attached ________ Additional Evidence List pages

Number of Pages
AFFIDAVIT OF COMPLAINT Page 6 of 6
STATE ELECTIONS ENFORCEMENT COMMISSION
Revised July 2012

VI. CERTIFICATION

1) Each Complainant must sign a separate page and each signature must be separately certified. This
complaint will not be considered filed without the name, address, and original certified signature of
at least one Complainant. Mail or hand-deliver this complaint to:

State Elections Enforcement Commission

55 Farmington Ave
Hartford, CT 06105

2) Once filed, this complaint may not be withdrawn by the Complainant(s) except by a vote of the State
Elections Enforcement Commission.

3) I am aware that criminal penalties may be imposed upon any Complainant who, under penalty of
false statement, knowingly files a false complaint.

4) The State Elections Enforcement Commission’s investigation of a complaint is confidential unless

and until the State Elections Enforcement Commission votes to authorize an investigation of a
complaint. Until such a vote, neither the Commission nor its staff will release or confirm any
information about the complaint except upon written request of a treasurer, deputy treasurer,
chairperson or candidate affiliated with a committee that is the subject of the complaint or
preliminary investigation.

Guides to the elections laws are available at http://www.ct.gov/seec

Connecticut General Statutes are available at http://www.cga.ct.gov

CERTIFICATION

I solemnly swear (or affirm) that the above statement is true and accurate
to the best of my knowledge and belief.

COMPLAINANT’S SIGNATURE DATE (mm/dd/yyyy)

Sworn and subscribed before me on this day of , 20 Seal

SIGNATURE OF PERSON ADMINISTERING THE OATH NAME OF PERSON ADMINISTERING THE OATH (Please Print)

TITLE OF PERSON ADMINISTERING THE OATH

Note: This oath may be administered by anyone authorized by Section 1-24 of the Connecticut General Statutes, which includes: notaries public; justices of the peace;
town clerks and assistant town clerks; judges and clerks of any court; and attorneys who are Commissioners of the Superior Court of Connecticut.
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