STATE OF CONNECTICUTSTATE ELECTIONSENFORCEMENT COMMISSroW*
8201020 Trinity Street Hartford, Connecticut 06106I
lSSION
Print Name of Com plainantTown/City of
Affidavit of ComplaintU ( v 4K\}fl&HL(Tftdm a resident of $?
gift
Print Town or City Name
and m y Telephone Number is
Print Comp lainant's Street AddressState of o ecc.Or
Obt&SPrint State & Zip Code~ * < * > t ' I hereby
allege and assert thatPrint Phone Number
the election laws of the State of Connecticut have been violated
in the following m anner,place and tim e, as specified below:
(Use attactK-'d page(s) if necessary)I SOLEMNLY SWEAR (OR
AFFIRM) THAT THE ABOVE STATEMENT IS TRUEAND COMPLETE TO THE BEST OF
MY KNOWLEDGEA ND BELIEF.Dated this
igned: ^JJU^JjignedOath A dm inistered By:Title (\. \.
