First Name Last Name Address: City: Zip Code: County: ADAMS ALLEGHENY ARMSTRONG BEAVER BEDFORD BERKS BLAIR BRADFORD BUCKS BUTLER CAMBRIA CAMERON CARBON CENTRE CHESTER CLARION CLEARFIELD CLINTON COLUMBIA CRAWFORD CUMBERLAND DAUPHIN DELAWARE ELK ERIE FAYETTE FOREST FRANKLIN FULTON GREENE HUNTINGDON INDIANA JEFFERSON JUNIATA LACKAWANNA LANCASTER LAWRENCE LEBANON LEHIGH LUZERNE LYCOMING McKEAN MERCER MIFFLIN MONROE MONTGOMERY MONTOUR NORTHAMPTON NORTHUMBERLAND PERRY PHILADELPHIA PIKE POTTER SCHUYLKILL SNYDER SOMERSET SULLIVAN SUSQUEHANNA TIOGA UNION VENANGO WARREN WASHINGTON WAYNE WESTMORELAND WYOMING YORK Date of Birth (mm/dd/yyyy): Phone E-mail Address

NOTE: Please complete the reCAPTCHA section and select continue below after reading the following affirmation. This website monitors and captures ISP information. By visiting this site, you consent to such monitoring. Any information that is voluntarily submitted via our online databases is collected, utilized, and maintained by the Department for the express purpose of referring complaints to the appropriate county board of elections and/or the district attorney. The disclosure of information provided with the online complaint system is voluntary; however, failing to provide certain information may result in the complaint not being appropriately filed. The confidentiality of the complaint information you provide may be affected by state laws, and as such, we cannot guarantee that your complaint information will remain confidential. If you chose to file a complaint using the online system, you do so voluntarily and acknowledge that all information will be disseminated to a county board of elections and/or district attorney, which may or may not take action on the complaint you reported. The Department does not have authority to conduct investigations into these matters and the Department does not participate in the decisions regarding which complaints may be investigated. Therefore, the Department cannot make any representations or guarantees either express or implied as to the action that may or may not be taken on any complaint filed with the online system.



