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Ethics Form

Ethics Form

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Published by PAindy

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Published by: PAindy on Oct 11, 2012
Copyright:Attribution Non-commercial

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10/11/2012

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CommonwealthorPennsylyania
StateEthicsCommissioD
SEC-3REVISED118/09
FOROFFICI.\LlS[0\"1.\
ETIDCSCOMPLAINT
Sendcompletedformto:
StateEthicsCommission309FinanceBuilding
P.O.
Box
11470Harrisburg,PA17108-1470(717)783-16101-800-932-0936www.ethics.state.pa.usINSTRUCTIONS-PleaseseePage1ofthisform
1.Identifythepersonyouarecomplainingabout.Name:
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Address:
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HomePhoneNumber:
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2.
Explainindetailwhyyoubelievethattheindividual
named
abovemayhaveviolatedtheEthicsAct.Attachan
extra
sheetofpaperifnecessary.
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3.Attachormakereferencetoanydocuments,materials,minutes,resolutionsorotherevidencewhichsupportyourallegations.
4.
Sworntoandsubscribedbeforemethis_______dayof
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20_
I
swearoraffinn.,underpenaltyofperjury,thatthefactssetforthinthiscomplaintaretrueandcorrecttothebestofmyknowledgeandbelief.
I
lso
swear
and
affirm
that[have
read
andunderstand
the
prohibitedretaliation,confidentiality,andwrongfuluseofactprovisionsonthefirstpageofthis
form,
NOW)'
Public
MyCommissionexpires:PrintfTypeyournarne:
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HomeAddress:WorkPhoneNumber:HomePhoneNumber:
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