COMPLAINT FORM

Please provide the following informaon about yourself:

Your name Telephone number

Email Address

Street address City State Zip code

Instrucons:  Clearly idenfy each person, commiee, or group that is alleged to have commied a violaon (called the respondent);  Clearly recite the facts that show specific violaons under the Commission’s jurisdicon (citaons to the law and administrave code are not necessary, but helpful); o Be as specific as possible as it relates to dates, mes, and individuals involved. Differenate between statements based on the complainant’s (the person who files the complaint) personal knowledge and those based on informaon and belief. Statements not based on personal knowledge should idenfy the source of the informaon, if known; Include any and all documentaon supporng the allegaons, if available; and Use as many separate pages as needed and aach copies of any supporng documentaon.  Please send this completed form to: Email: Fax: Mail: [email protected] (608) 264‐9319 Wisconsin Ethics Commission P.O. Box 7125 Madison, WI 53707‐7125

State of Wisconsin Before the Ethics Commission

The Complaint of ______

______, Complainant(s) against

______, Respondent, whose

address is ______.

This complaint is under ______(Insert the applicable secons of law in chapters 11, subchapter III of ch. 13, or subchapter III of ch. 19 of Wisconsin Statutes, if known)

ETH-10 (Revised March 2019) | Ethics Commission | https://ethics.wi.gov | [email protected] COMPLAINT FORM

I, ______, allege that:

______

______

______

______

______

______

I, ______, being first duly sworn, on oath, state that I person‐ ally read the above complaint, and that the above allegaons are true based on my personal knowledge and, as to those stated on informaon and belief, I believe them to be true.

Date: ______Complainant’s Signature STATE OF WISCONSIN

County of ______, (county of notarizaon)

Sworn to before me this _____ day of

______, 20_____.

______(Signature of person authorized to administer oaths)

My commission expires ______, or is permanent.

Notary Public or ______(official tle if not notary)

ETH-10 (Revised March 2019) | Ethics Commission | https://ethics.wi.gov | [email protected]