Form Ss984N – Fill Out and Use This PDF

Name of person filing document

Address

City

State

Zip Code

Daytime phone number	Fax number	Email address

Mailing Address: P. O. Box 94125, Baton Rouge, LA * 70804-9125

Office Location: 8585 Archives Ave., Baton Rouge, LA * 70809

Web Site Address: www.sos.la.gov

SS984N Rev. 08/13

	COMPLAINT ALLEGING
	UNAUTHORIZED EXERCISE OF NOTARIAL POWERS
	La. R.S. 35:601 et seq.
	RETURN COMPLETED FORM TO:
Tom Schedler	Secretary of State Notary Division,
Secretary of State	P.O. Box 94125
	Baton Rouge, LA 70804

Parish of _____________________________

Before me, the undersigned authority came and appeared the undersigned complainant, who in accordance with the provisions of La. R.S. 35:603, and being duly sworn, did depose and say that

_______________________________________________	_______________________ is in violation of the
Printed name of subject of complaint	Notary ID# if known

following provision(s) of La. R.S. 601 et seq. (UNAUTHORIZED EXERCISE OF NOTARIAL POWERS)

Violation(s): check all that apply

_____ Commission or authority to exercise notary function is statutorily or judicially suspended.

_____ Commission or authority to exercise notary function is statutorily or administratively revoked.

_____ No longer validly commissioned.

_____ Commission in retirement status under provisions of R.S.35:202(G)

_____ No longer validly possessed of the office or position from which authority to exercise notarial functions were derived.

_____ Convicted of a felony and has not been pardoned.

_____ Not authorized by law to exercise that particular notarial function.

_____ Engaged in dishonesty, fraud, deceit, or misrepresentation.

_____ Certified as true what he knows or should have known to be false.

_____ Violated any provision of any law governing the office of notary or the exercise of notary authority.

_____ Abandoned his commission.

_____ Failed to pay over money entrusted to him in his official capacity as a notary public.

_____ Failed to satisfy any final judgment rendered against him in his official capacity as a notary public.

_____ Not authorized to exercise notarial powers.

Complainant’s statement to include details of violation(s), its nature, the dates, time(s), address(es) where violation(s) occurred and address of subject of the complaint. (attach additional page(s) if necessary):

__________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

Complainant name:_________________________________________ Phone: _________________________________

Complainant address: _______________________________________ City, State, Zip:__________________________

_____________________________________

Signature of Complainant

Sworn to and subscribed before me this ____ day of ___________, 20___

__________________________________________

Signature of notary

__________________________________________ ________________

Printed name of notary

La. Notary ID#