- Information about purchaser or complainant (You)
Today's Date*
Name (Last, First, Middle)*
Home Address*
Home Phone number*
Business Phone number
Email Address
Are you willing to be interviewed by an investigator from this office?*
Yes
No
Are you willing to be a witness if formal proceedings are commenced by the Securities Commissioner?*
Yes
No
- In what did you purchase or invest? (i.e. common stock, debenture, limited partnership, investment contract).
a. Type of Security
Other:
Number of Shares
Total Amount Invested*
Date Purchased
b. In what company, corporation or association did you invest?*
(Company Name, Address, Phone Number)
c. Give information regarding the persons involved in the transaction.
(i.e. Name, Address, Phone Number)
d. How were you contacted?
- Please provide a brief narrative of the transactions which gave rise to your complaint, including any relevant internet information.*
- Have you complained to the subject or seller?*
Yes
No
If yes, what offer of adjustment or explanation was made?
- Any Additional Information
- What would you consider to be a satisfactory solution?*