Page 1 of

AFFIDAVIT OF COMPLAINT awa G

STATE ELECTIONS ENFORCEMENT COMMISSION r

Revised July 2012

o•

AN

Please complete this form to the fullest extent poS MfUON

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

I. IDENTITY OF COMPLAINANT(S)
COMPLAINANT' S NAME
MI La, Name Sull-ix
First Name

Robert J Dempsky

COMPLAINANT' S STREET ADDRESS

Address

36 River Avenue

till( ode
Citydate
Norwich CT 06360

COMPLAINANT' S TELEPHONE NUMBER

Work Cell
Home
860) 608- 4483

COMPLAINANT' S EMAIL ADDRESS

RJDNorwichRTC@gmail. com

COMPLAINANT' S NAME
M1 last Name Suffix
Iir,\ amc

COMPLAINANT' S STREET ADDRESS

Address

State Zip Code

COMPLAINANT' S TELEPHONE NUMBER

I loins Work

COMPLAINANT' S EMAIL ADDRESS

COMPLAEANT' S NAME
Last Name sufl- l'
1- ir, t game MI

COMPLAINANT' S STREET ADDRESS

Address

City.
state Zip Code

COMPLAINANT' S TELEPHONE NUMBER

work ell
Home

COMPLAINANT' S EMAIL ADDRESS

 AFFIDAVIT OF COMPLAINT Page 2 Ott 6

STATE

Revised
ELECTIONS

July 2012
ENFORCEMENT COMMISSION

Q
U. IDENTITY OF RESPONDENT( S)

RESPONDENT' S NAME ( Ifknown; otherwise write" unknown')

First Name MI Laat Nana Suffix

Derell Q Wilson

RESPONDENT' S STREET ADDRESS ( Ifknown)

Address

30 Second Street

City State Zip Code

Norwich
CT 06360

RESPONDENT' S TELEPHONE NUMBER ( Ifknown)

Home Work Cell
860) 886- 5971 860) 639- 67534

RESPONDENT' S EMAIL ADDRESS ( Ifknown) STATUTE( S) VIOLATED ( Ifknown)

dwilson2941cnetzero. net 9- 140

RESPONDENT' S NAME ( Ifknown, otherivise write" unknown')

First Name MI Last Name Suffix

RESPONDENT' S STREET ADDRESS ( 11' know7t)

Address

City State Zip Code

RESPONDENT' S TELEPHONE NUMBER ( Ifknown)

Home Work

RESPONDENT' S EMAIL ADDRESS ( Ifknown) STATUTE( S) VIOLATED ( Ifknown)

RESPONDENT' S NAME ( Ifknown, otherwise write" unknown" I

First Name MI Lau Name Suffix

RESPONDENT' S STREET ADDRESS ( If known)

Address

City State Zip Code

RESPONDENT' S TELEPHONE NUMBER ( Ifknown)

Home Work Cell

RESPONDENT' S EMAIL ADDRESS ( yknown) STATUTE( S) VIOLATED( Ifknown)

Copy and attach page( s) for additional respondents ifnecessary.

Please check " See attached Additional Respondent List" and list the number ofpages.
See attached Additional Respondent List pages
Number of Pages
AFFIDAVIT OF COMPLAINTPage 3 of 6
STATE ELECTIONS

July 2012
ENFORCEMENT

COM 0-
III. VIOLATION( S) ALLEGED

DATE( S) OF ALLEGED VIOLATION( S)( Ifknown)

10104121- 1012812021

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-
fiedrespondents, 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:

On at least October 28, 2021 but possibly on dates prior to it, the respondent was issued 1710 absentee ballot request( ABR)

forms for use in the 2021 elections held by the City of Norwich. Included are four ABRs bearing an electronic signiature in place of

the in person or" wet" signiature required by statute 9- 140.( See Evidentiary Attachments A- C.) Additionally, a letter using the

same electronic signiature of the respondent was mailed with the absentee ballot request forms.( See Evidentiary Attachment D.)

This letter references the February election for State Senate( 2021- 041) in which identical tactics were employed and subsequenth

determined to be improper by Ted Bromley, CT Director of Elections, and the SEEC. This letter also fails to properly enumerate all

of the eligiblity requirements, as required by statute.

Use attached page( s), for additional statement offacts if necessary.

Please check " See attached Additional Statement ofFacts" and list the number ofpages.
See attached Additional Statement of Facts pages
I: umia: r of Pap.>
AFFIDAVIT OF COMPLAINT
STATE ELECTIONS
Revised July 2012
ENFORCEMENT COMMISSION

Q
ADDITIONAL STATEMENT OF FACTS
Pave of

CONCISE STATEMENT OF FACTS continued

 surr

C
AFFIDAVIT OF COMPLAINT a=°,
r
Page 4 of 6

STATE ELECTIONS ENFORCEMENT COMMISSION r

ti-.,
Revised July 2012
a

IV. WITNESSES
WITNESS' S NAME ( Ifknown)

First Name MI Last Name Suffix

WITNESS' S STREET ADDRESS ( Ifknown)

Address

City State Zip Codc

WITNESS' S TELEPHONE NUMBER (# known)

Home Work Cell

WITNESS' S EMAIL ADDRESS ( Ifknown)

WITNESS' S NAME ( Ifknown)

First Name Ml Last Name Suffix

WITNESS' S STREET ADDRESS ( Ifknown)

Address

CityStatc Zip Code

WITNESS' S TELEPHONE NUMBER ( ffknown)

Home Work Cell

WITNESS' S EMAIL ADDRESS ( Ifknown)

WITNESS' S NAME ( Ifknown)

First Narue Ml Last Name suffix

WITNESS' S STREET ADDRESS ( Ifknown)

Address

City State Zip Code

WITNESS' S TELEPHONE NUMBER ( Ifknown)

Home Work Cell

WITNESS' S EMAIL ADDRESS ( Ifknown)

Copy and attach page(s) for additional witnesses ifnecessary.

Please check " See attached Additional Witness List" and list the number ofpages.
See attached Additional Witness List pages
Number of Pages
 Page 5 of 6
AFFIDAVIT OF COMPLAINT `
STATE ELECTIONS ENFORCEMENT COMMISSION l
2 R

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
Number of Pages
Title

Absentee Ballot Request Form# 1 1

Date of Publication
Author

N/ A N/ A

Date Acquired
How Acquired

Delivery from an individual 11/ 01/ 21

EVIDENTIARY ATTACHMENT
Number of Pages
Title

Absentee Ballot Request Form# 2 1

Date of Publication
Author

N/ A N/ A

Date Acquired
How Acquired

Delivery from an individual 11/ 01/ 21

EVIDENTIARY ATTACHMENT
Number of Pages
Title

Absentee Ballot Request Form# 3 1

Date of Publication
Author

N/ A N/ A

Date Acquired
How Acquired

Delivery from an individual 11/ 01/ 21

EVIDENTIARY ATTACHMENT
Number of Pages
rifle

Absentee Ballot Request Insert 1

Author Date of Publication

N/ A N/ A

How Acquired Date Acquired

Delivery from an individual 11/ 01/ 21

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

Please check " See attached Additional Evidence List" and list the number ofpages.

See attached Additional Evidence List pages

Number of Pages
 Page 6 of 6
AFFIDAVIT OF COMPLAINT = 6 `

STATE ELECTIONS ENFORCEMENT COMMISSION ( .

o
Revised July 2012
o+

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. et. gov/ seec
Connecticut General Statutes are available at http:// www. ega. et.$!ov

CERTIFICATION

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

11/ 2172

COMPLAINANT' S S ATURE DATE( mm/ dd/ yyyy)

r he'' J• ew+ SIB

29 November 21
Sworn and subscribed before me on this day of 20 Seal

n pr1 e L . ffY Q
SIG AT RE OF P ON ADMINISTERING THE OATH NAME OF PERSON ADMINISTERING THE OATH ( Pimw Prim)

NICOLE L MATOS
NOTARY PUBLIC
State of Connecticut

t My Commission Expires 9/ 30/ 2026

TITLE OF PERSON ADMINISTEI ING 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.
THIS PAGE INTENTIONALLY LEFT BLANK
 NMWIC H

APPLICATION FOR ABSENTEE BALLOT

Pursuant to Senate Bill 1202 of the June Special Session 2021, COVID-19 may be used as
a valid reason for requesting a ballot for any Primary, Election or Referendum held
before November 3, 2021.

Section I.—Applicant' s Information

Name:
Date of Birth For Municipal Clerk' s Use
Home Address:
Zip Code06360
Number, Street, Town) Outer Envelo a Serial No.
a
Telephone No E- mail Address Da a orms sue
a
Mailing Address: Check ailed to Given to
Applicant Applicant

177 Personally
Use Orly the is differentJtom
mailing address the address above.) i
Pol. Subdivision
Vo" 9DistnctNo.
Section H.— Statement of Applicant- Required r`'' l

I, the undersigned applicant, believe that I am eligible to vote at the Primary, Election or
Referendum held in my municipality. I expect to be unable to appear at the polling place during the hours of voting and hereby apply
for an absentee ballot:( you MUST check one)
COVID- 19
All voters are able to check this box, pursuant to Senate Bill 1202 of the June Special Session 2021- 4
My active service in the Armed Forces of the United States N
i
My absence from the town during all of the hours of voting O

My illness
N
My religious tenets forbid secular activity on the day of the election, primary or referendum
n CA
rn
My duties as a primary, election or referendum official at a polling place other than my own dur zgp of the l tars of
Y
voting lrn

M E
My physical disability
For Referendum( Date For Primary( Date Party

For Military/ Overseas Personnel only, please indicate if you would like your absentee ballot sent to you electronically to the email
address provided above ( Yes No__)

Section M.—Applicant' s Declaration- Required

I declare, under the penalties of false statement in absentee balloting, that the above statements are true and correct, and that I am the
applicant named above. ( Sign your legal name inluiL Ifyou are unable to write, you may authorize some one to write your name and the date in the spaces
provided followed by the wo at re o the authorized person Such person must also complete section IV below.)

Signature of Applicant Date Signed:

Section IV. —Declaration of person providing assistance( Completed by any person who assists with completion ofapplication)
I sign this application under penalties of false statement in absentee balloting.

Signature:_
If t j
t Printed Name: Derell Wilson Tel. No: ( 860) 886- 5971

Residence Address: 30 2nd St Norwich CT 06360

SPECIAL INSTRUCTIONS
Connecticut law allows you to receive an absentee ballot if you cannot appear at your assigned polling place on election day
because of active service in the Military, absence from the town during all of the hours of voting, illness, religious tenets forbid
secular activity on the day of the election, duties as an election official at a polling place other than your own during all of the
hours of voting, or physical disability, The State of Connecticut, via Senate Bill 1202 of the June Special Session 2021, has
determined that the existence of the COVID- 19 virus allows you to vote by absentee ballot if you so choose for your own safety. To
and this application and return it to your Town Clerk.
your absentee ballot please complete
sign
receive
 NORWICH

APPLICATION FOR ABSENTEE BALLOT

Pursuant to Senate Bill 1202 of the June Special Session 2021, COVID- 19 may be used as
a valid reason for requesting a ballot for any Primary, Election or Referendum held
before November 3, 2021.

Section I.—Applicant' s Information

Name: Date of
Birth For Municipal Clerk' s Use
Home Address: Code
Zip 06360
erial No.
um er, eet, own

a e 0 ssue
Telephone No E- mail Address
bb

Check aile o Given to

Mailing Address:
Applicant Applicant

Personally

12 JG aILty f the' nlailitig address is dyferent fi-oni the address above.)

176
Z
Pol. Subdivision Voting District No.
Section II.—Statement of Applicant- Required

I, the undersigned applicant, believe that I am eligible to vote at the Primary, Election or I
Referendum held in my municipality. I expect to be unable to appear at the polling place during the hours o voting and hereby apply
for an absentee ballot:( you MUST check one)
X'COVID- 19 All voters are able to check this box, pursuant to Senate Bill 1202 of the June Special Session 2021- 4
My active service in the Armed Forces of the United States
My absence from the town during all of the hours of voting
My illness
of the or referendum 1
My religious tenets forbid secular activity on the day election, primary
N

referendum official at a polling place other than my own of thr

urs 7
duties
during
or
My as a
primary, election

voting M
Oz
My physical disability C
For Primary( Date Party
For Referendum( Date

For Military/ Overseas Personnel only, please

indicate if you would like your absentee ballot ser u elect
1picallyd* e email

address provided above ( Yes_ No__) M

Q
Section III.—Applicant' s Declaration- Required
I declare, under the penalties of false statement in absentee balloting, that the above statements are true and correct, and that I am the
applicant named above. si t our legal name in full Ifyou are unable to write, you may authorize some one to write your name anizme date in the spaces
on. Such person must also complete section IV below.)
provided followed
by the wo

Date Signed:
Signature of Applicant

Section IV.—Declarati of person providing assistaIIce( Completed by any person who assists with completion ofapplication)
I sign this application under penalties of false statement in absentee balloting.
Tel. No: ( 860) 886- 5971
Printed Name: Derell Wilson
Signature:

Residence Address: 30 2nd St., Norwich Cr 06360

SPECIAL INSTRUCTIONS
Connecticut law allows you to receive an absentee ballot if you cannot appear at your assigned polling place on election day
because of active service in the Military, absence from the town during all of the hours of voting, illness, religious tenets forbid
secular activity on the day of the election, duties as an election official at a polling place other than your own during all of the
hours of voting, or physical disability. The State of Connecticut, via Senate Bill 1202 of the June Special Session 2021, has
determined that the existence of the COVID- 19 virus allows you to vote by absentee ballot if you so choose for your own safety. To
complete and sign this application and return it to your Town Clerk.
receive your absentee ballot please
 NORWICH

APPLICATION FOR ABSENTEE BALLOT

Pursuant to Senate Bill 1202 of the June Special Session 2021, COVID- 19 may be used as
a valid November
before reason for 3,requesting
2021. a ballot for any Primary, Election or Referendum held
Section I.-
Applicant' s Information
Name:
Date of Birth
For Municipal Clerk' s Use
Home Address:
Zip Code 06360
Number, Street, Town) Out No.

Telephone No. E- mail Address Date o issu

1
Mailing Address: Check aileA to Given to

Applicant Applicant
0110. Personally
1391

Use only ifthe mailing address is di.f erentfrom the address above)
Pol. Subdivision Voting District No.
Section U.- Statement of Applicant- Required
I, the undersigned applicant, believe that I am eligible to vote at the Primary, Election or
Referendum held in my municipality. I expect to be unable to appear at the polling place during the hours of voting and hereby apply
for an absentee ballot:( you MUST check one)
VCOVID- 19
All voters are able to check this box, pursuant to Senate Bill 1202 of the June Special Session 2021 t
My active service in the Armed Forces of the United States
My absence from the town dining all of the hours of voting
My illness
My religious tenets forbid secular activity on the day of the election, primary or referendum
N

My duties as a
primary, election or referendum official at a
polling place other than my own duri all of t}% our

voting n
My physical disability
For Referendum( Date For Primary( Date Q/ Party
C

For Military/ Overseas Personnel only, please indicate if you would like your absentee ballot sent u
electroically e email
address provided above ( Yes No 4{" r
70 .
M.- Applicant' s Declaration- Required 3
19
I declare, under the penalties of false statement in absentee balloting, that the above statements are true and correct, and that I am the
applicant named above. ( Sign your legal name in full. Ifyou are unable to write, you may authorize some one to write your name and the date in the spaces
provided followed by the word" b " and the si iature o the authorized persom Such erson must also complete section IV below)

Signature of Applicant: Date Signed:_ \ M au , L 1

Section IV.—Declaration of person providing assistance( Completed by any person who assists with completion of application)
of false statement in absentee balloting.
I sign this application under penalties

Signature: 0,00 Printed Name: Derell Wilson Tel. No: ( 860) 886- 5971

Residence Address: 30 2nd St., Norwich CT 06360

SPECIAL INSTRUCTIONS
Connecticut law allows you to receive an absentee ballot if you cannot appear at your assigned polling place on election day
because of active service in the Military, absence from the town during all of the hours of voting, illness, religious tenets forbid
secular activity on the day of the election, duties as an election official at a polling place other than your own during all of the
hours of voting, or physical disability. The State of Connecticut, via Senate Bill 1202 of the June Special Session 2021, has
determined that the existence of the COVID- 19 virus allows you to vote by absentee
it
ballot ifTown
you soClerk.
choose for your own safety. To
complete and sign this application and return to your
receive your absentee ballot please
 N 0 RW I C H
DEMOCRATS

Dear-

Tuesday, November 2, is Election Day, and because of the pandemic, all voters are once
again eligible to vote by Absentee Ballot.

Make no mistake, this election is critical. It will determine if we defeat Trumpism once and for
all, or if it will be allowed to rear its ugly head again.

In Connecticut, Republicans Flipped an important State Senate seat just a few short weeks
ago. We can' t afford a similar result in Norwich. The future of our country is at stake; join us in
holding all local Republicans accountable.

Complete the enclosed, partially pre- filled application and return it to the City Clerk' s office as
soon as possible.

Step 1: Check the COVID box( or another box, if one applies to you)
Step 2: Sign& date your application
Step 3: Mail it( don' t forget a stamp) to the City Clerk or put it in the drop box at City Hail

Again, YOU can vote by Absentee Ballot due to the pandemic. You can also vote by
Absentee Ballot if you are away from Norwich during voting hours. serve in the Armed Forces,
have an illness or physical disability, or observe a religion that forbids secular activity on
November 2. There are civil and criminal penalties for falsely voting by absentee ballet, but all
voters are permitted to vote absentee this election.

If you have questions about voting by absentee ballot, you can call the Norwich City Clerk
at( 860) 823- 3732.

Let' s ensure that not one Trump Republican ever holds office again. Return your
application today. Let' s stand together one more time.

04rely, a
Derell Wilson
Chairman, Norwich Democrats

Pard for by ae[ ler— ri for Mayor. Mark KuW Treasurer, and Responsible Leadership for Norwich 2021. Linda Theodora,
Treasurer. Approved by Mark Beffencoun and Responsible Leadership for Norwich 2021,