Administrative Complaint Procedure Form
TERRITORY OF THE VIRGIN ISLANDS TITLE III HELP AMERICA VOTE ACT (HAVA) COMPLAINT FORM This complaint form if for violation of Title III of HAVA that you believe has occurred, is occurring or is about to occur. Check which of the following best describes the reason you believe a Title III violation occurred, is occurring or is about to occur? Voting machine/system(s) Accessibility for Individuals with Disabilities Provisional Voting or Voter information Computerized Territory wide Voter Registration List Other Instruction/checklist: The following information is required in order for the complaint to be processed. Please Print. o Complete all information. Failure to complete the required information will result in the complaint being dismissed. o According to federal law, all HAVA complaints must be in writing and notarized. All complaints must be signed and sworn to by the person filing the complaint. o You may attach any written material or other information that you believe is relevant to your complaint. o This complaint is not confidential. …
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TERRITORY OF THE VIRGIN ISLANDS TITLE III HELP AMERICA VOTE ACT (HAVA) COMPLAINT FORM This complaint form if for violation of Title III of HAVA that you believe has occurred, is occurring or is about to occur. Check which of the following best describes the reason you believe a Title III violation occurred, is occurring or is about to occur? Voting machine/system(s) Accessibility for Individuals with Disabilities Provisional Voting or Voter information Computerized Territory wide Voter Registration List Other Instruction/checklist: The following information is required in order for the complaint to be processed. Please Print. o Complete all information. Failure to complete the required information will result in the complaint being dismissed. o According to federal law, all HAVA complaints must be in writing and notarized. All complaints must be signed and sworn to by the person filing the complaint. o You may attach any written material or other information that you believe is relevant to your complaint. o This complaint is not confidential. Once filed with the Office of the Supervisor, it will be treated as a public record and any decision will be published on the Election System’s website. You may request a hearing on the record, a formal hearing. o You will receive a written response within 90 days of the complaint being filed. 1. Complainant’s Information: A. Complainant’s Name:______________________________ B. Mailing Address:__________________________________ C. City___________________, State____________________ Zip Code____ D. Home No___________, Business No.____________, Cell No._________ 2. What is the name and /or activity and the location of the Title III violation? A. Name of individual who violated Title III:__________________ (include in what capacity they served in relation to the violation)