Securities Complaint Form

Office of the Securities Commissioner

* Required fields

Your Information
* First Name:
* Last Name:
* Address:
* City:
* State:
* Zip:
* E-mail:
* Phone number where you can be reached during business hours:
Birthdate:
Occupation:
Business Address:
City:
State:
Zip:
Business phone:
Fax number:
Who is your complaint against?
* Business Name:
Address:
City:
State:
Zip:
E-mail/Website:
Phone number:
Individual Involved:
Title:
Individual Involved:
Title:
Transaction Information
Date of Transaction/Purchase:
Product Involved:
What was the transaction for?:
Amount Paid:
Paid by:
Date of Payment:
Who received payment from you?:
How many units or shares did you purchase?:
Did you sign a contract?:
Did you have a verbal agreement?:
Where did the transaction take place?:
Had you any prior business relationship with either the company or the salesperson?:
What was the first contact between you and the company?:


Actions You Have Taken

Do you know of any other persons who invested with the company, corporation or association? If so, please provide their name, address and telephone number:

Have you notified or filed a complaint with another agency? If so, please describe:

Have you complained to the subject or seller? If yes, what offer of adjustment or explanation was made?

Who made the offer of adjustment?

What would you consider to be a satisfactory solution?