Code of Ethics Violation Form (PDF)

(Revised Jan. 2025) 
 
Complaint of Violation of Code of Ethics 
Please provide the information requested below and attach additional sheets if necessary. 
1. Identify the person who is alleged to have violated the Ethics Code. 
 
 
 
 
 
2. Specific Code of Ethics Violation:  Section 2.50.030 ___  [insert applicable subsection’s letter] 
Go to https://www.waterfordct.org/ (click on Ordinances/Policies) or contact the Town Clerk for a hard copy of the Ethics Code. 
 
3. Provide a detailed explanation of the nature of the violation. Include dates, places and corroborating witnesses or 
documents, if any. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Signed by: ______________________________________ 
Date: __________ 
Telephone: ___________________ 
Print Name:   ____________________________________ 
Email:  _______________________________________ 
Address:  __________________________________________________________________________________________ 
 
Acknowledgement: State of Connecticut, County of _______________________ , Town of _______________________ 
On this the  _____   day of   __________________ , ________ ,  before me, the undersigned officer, personally appeared 
__________________________________ , known to me (or satisfactorily proven) to be the person whose name is subscribed  
to the within instrument and acknowledged that (he, she, they) executed the same for the purposes therein contained.  
In witness thereof I hereunto set my hand. 
Signature:  ______________________________________ 
Position:  _____________________________________ 
Print Name:  ______________________________________ 
Witness must be (1) a judge of a court of record, (2) a clerk or deputy clerk of a court having a seal, (3) the town clerk,  
(4) a notary public, (5) a justice of the peace, or (6) an attorney admitted to the bar of this state. 
Submit this complaint in a sealed envelope. Mail or hand-deliver completed form to Ethics Commission c/o 
Town Clerk, 15 Rope Ferry Rd, Waterford CT 06385. Complaints must be kept strictly confidential to remain 
viable except upon the request of the respondent. 
Name:  ______________________________________________________________________________ 
Title or Position:  ______________________________________________________________________ 
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