Complaint Form 
 
HAVA Complaint Form 402 (August 2004) 
Under section 402(a)(2) of the Help America Vote Act of 2002 (HAVA), P.L. 107-252 and Washington 
Administrative Code, Chapter 434-263, any person who believes that a violation of any provision of 
Title III of HAVA has occurred, is occurring, or is about to occur, may file a complaint with the Office of 
the Secretary of State.  This form may be used to file such complaints.  However, a letter containing 
the below information will be considered an acceptable complaint as well.  All complaints must be 
notarized and filed within thirty (30) calendar days of the date after the certification of the election at 
issue and sent to the Washington Secretary of State, Elections Division, Post Office Box 40229, 
Olympia, WA 98504-0229.  The state shall make a final determination within 90 days of receiving the 
complaint. 
 
Thank you for taking the time to make this complaint 
 
 
A. Person Making Complaint 
Last Name                                                                                            First                                                                                                    Middle Initial 
Street address                                                  
 
City 
 
County 
 
State 
Zip Code 
 
Home Telephone Number  
(           )              
Work Telephone Number  
(           )              
Email Address (optional) 
 
 
 
B. Description of the Alleged Violation 
Please identify:  
1.  The facts of the alleged violation 
2.  Witnesses, if any, and contact information if you have it 
3.  Date and time you became aware of the alleged violation 
4. Location where the alleged violation occurred 
5. Who is responsible for the alleged violation 
6. Other information that you think will be helpful in resolving your complaint 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If you need more room to describe the alleged violation, please attach another page.  
 
 
I hereby certify that the information provided above is true and correct to the best of my knowledge. 
 
 
_______________________________________ 
Complainant Signature 
 
 
Please have a Notary Public complete the below section 
 
 
Subscribed and sworn to (or affirmed) before me this _______ Day  
Of _____________________________, 20 _____. 
 
 
_____________________________________________ 
Notary Public 
 
My Commission Expires on: 
_____________________________________________