SWORN COMPLAINT BEFORE THE MONTGOMERY COUNTY ETHICS COMMITTEE An individual must be at least 18 years of age to be eligible to submit a sworn complaint to the Montgomery County Ethics Committee, c/o the Montgomery County Attorney. Complaints must be sworn to and signed in front of a Notary Public or other Authorized Official. A complaint must be submitted within 60 c a l e n d a r days of the date the alleged conduct is discovered. If the 60th day falls on a day the county is not open for business, the complaint may be filed by the end of the next county business day. A complaint is considered submitted on the date it is received by the County Attorney. Check the box that applies: Original Complaint Amended Complaint Supplemental Complaint OFFICE USE ONLY Docket Number Date Hand-delivered or Date Postmarked 1 COMPLAINANT NAME I. IDENTITY OF PERSON MAKING COMPLAINT (COMPLAINANT) MS / MRS / MR FIRST MI r NICKNAME LAST SUFFIX 2 COMPLAINANT PHYSICAL (Optional) 3 COMPLAINANT MAILING (check if same as above) 4 COMPLAINANT TELEPHONE NUMBER (Optional if e- mail address provided) 6 RESPONDENT NAME (Full home or business address, including street, city, state, and zip code) (Full home or business address, including street, city, state, and zip code) AREA CODE PHONE NUMBER EXT 5 COMPLAINANT E-MAIL II. IDENTITY OF PERSON COMPLAINED ABOUT (RESPONDENT) MS / MRS / MR FIRST MI NICKNAME LAST SUFFIX 7 RESPONDENT POSITION OR TITLE 8 RESPONDENT BUSINESS (IF KNOWN) 9 RESPONDENT MAILING (check if same as above) 10 RESPONDENT TELEPHONE NUMBER (IF KNOWN) (Full home or business address, including street, city, state, and zip code) AREA CODE EXT PHONE NUMBER 11 RESPONDENT E-MAIL (IF KNOWN) GO TO PAGE 2
III. NATURE OF ALLEGED VIOLATION Page 2 Include the nature of the alleged violation, including the specific rule or provision of the Code of Ethics alleged to have been violated.
IV. STATEMENT OF FACTS Page 3 State the facts constituting the alleged violation(s), including the dates on which or the period of time in which the alleged violation(s) occurred. All factual allegations should be the complainant s personal knowledge and/or personally observed by the complainant. The facts alleged should not be based upon hearsay, rumor or what someone else alleges occurred. Please use simple, concise, and direct statements.
V. LISTING OF DOCUMENTS AND OTHER MATERIALS Page 4 List all documents and other materials filed with this complaint. Additionally, list all other documents and other materials that are relevant to this complaint that you are not able to obtain, including their location, if known.
VI. LISTING OF WITNESSES Page 5 List all witnesses who may have information relevant to your complaint. Identify the information they have and provide the witness s current contact information, if known. 1 WITNESS NAME: MS / MRS / MR: FIRST: MI: NICKNAME: LAST: SUFFIX: 2 WITNESS HOME OR BUSINESS PHYSICAL : (Optional) 3 WITNESS HOME OR BUSINESS MAILING : (Optional) (check if same as above) 4 WITNESS TELEPHONE NUMBER: (Optional if e-mail address provided) 6 Information Witness May Provide: AREA CODE PHONE NUMBER EXT 5 WITNESS E-MAIL : 1 WITNESS NAME: MS / MRS / MR: FIRST: MI: NICKNAME: LAST: SUFFIX: 2 WITNESS HOME OR BUSINESS PHYSICAL : (Optional) 3 WITNESS HOME OR BUSINESS MAILING : (Optional) (check if same as above) 4 WITNESS TELEPHONE NUMBER: (Optional if e-mail address provided) 6 Information Witness May Provide: AREA CODE PHONE NUMBER EXT 5 WITNESS E-MAIL :
VII. AFFIDAVIT Page 6 BASED ON PERSONAL KNOWLEDGE (Execute this affidavit if the acts alleged are within your direct personal knowledge.) I,, complainant, swear that I am at least 18 years of age. I swear that I am submitting this complaint in good faith and not to harass, annoy or embarrass. I swear that I have p e r s o n a l knowledge of the facts alleged in this complaint and that the information contained in this complaint is true and correct to the best of my knowledge. Signature of Complainant AFFIX NOTARY STAMP / SEAL ABOVE Sworn to and subscribed before me, by the said, this the day of, 20, to certify which, witness my hand and seal of office. Signature of officer administering oath Printed name of officer administering oath Title of officer administering oath