1. Date of Complaint:
2. Name of Complainant:
3. Complainant Contact Information:
Address:
Telephone: Fax:
Email:
4. I make this complaint under oath against
(County Officer) who is
(Describe Officer’s Title or Job Description).
I believe (County Officer) has violated the County Ethics Ordinance,
Section(s) .
(Attach copies of pertinent documents, dates, facts, and circumstances)
5. I agree to cooperate with persons assigned to investigate this complaint.
Yes No
6. I am willing to appear and testify, if a public hearing is conducted on these charges.
Yes No
7. The facts in this complaint are true to the best of my knowledge and belief.
Yes No
8. I understand pursuant to KRS 523.010 et seq. a false statement made under oath and without belief could affect the outcome of any proceeding before the Ethics commission and may subject me to penalties including fines of up to $500 or 12 (twelve) months imprisonment.
VERIFICATION
Complainant
I, (the complainant), having been duly sworn, declare under oath that the above is true to the best of my knowledge.
Signature
Dated this day of , 20 .
STATE OF
COUNTY OF
Subscribed and sworn to before me this day of , 20 .
Notary Public
My Commission Expires:
(Ord. 556, passed passed 3-17-2015)