Idaho > Secretary Of State > Blue Sky > Department Of Finance > Securities Bureau
Complaint Form - Idaho
| Complaint Form Form. This is a Idaho form and can be used in Securities Bureau Department Of Finance Blue Sky Secretary Of State . |
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IDAHO DEPARTMENT OF FINANCE Securities Bureau 800 Park Blvd., Suite 200, Boise, ID 83712 P.O. Box 83720, Boise, ID 83720-0031 Website: finance.idaho.gov Fax: 208/332-8099 208/332-8004 GUIDELINES FOR COMPLETING THE SECURITIES COMPLAINT FORM Before filling out the attached complaint form, please take the time to read these guidelines; they will help you understand our functions, and we will be better able to understand and act on your complaint. WHAT WE CAN DO: We investigate complaints against persons, business entities, and corporations accused of violating the licensing or anti -fraud provisions of laws administered by the Department. We are empowered to bring administrative or civil actions to stop these violations, and, in appropriate cases, to refer matters to the Prosecuting Attorneys' offices for criminal prosecution. WHAT WE CANNOT DO: We cannot act as a court of law, so we cannot order that monies be refunded, contracts be canceled or damages be awarded. If you have this type of problem, you should consult an attorney. We cannot give legal advice or act as your attorney. HOW YOU CAN HELP US: The purpose of this complaint form is to provide this Department with enough information to allow us to determine if an investigation into your allegations is warranted. Thus, it is important for you to furnish as much detailed information as possible. Documentary evidence is especially important, therefore, you should photocopy all documents such as account statements, contracts, agreements, certificates, notes, trust deeds, correspondence, legible copies of the front and back of checks involved, escrow documents, advertising, etc., and attach them to the written complaint. (Please do not send originals; we cannot be responsible for their safekeeping.) Type or print clearly in ink. If you have any questions concerning this form, you may contact the Securities Bureau at 208/332-8004. Upon completion of all sections, please mail the form along with your supporting documents to: Idaho Department of Finance Securities Bureau P.O. Box 83720, Boise, ID 83720-0031 or Express: 800 Park Blvd., Suite 200, Boise, ID 83712 American LegalNet, Inc. www.FormsWorkFlow.com COMPLAINT FORM INFORMATION ABOUT YOU A. Last Name First Middle Today's Date Home Address ( City State Zip ) Telephone Number Business Address ( City State Zip ) Telephone Number Email Address Trade or Occupation Age Marital Status 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 Idaho Department of Finance? Yes No SUBJECT OF COMPLAINT B. Company Name Address Telephone No. List persons who were involved in selling you the investment (please use separate pages to set forth any other available information about these persons.) Last Name No. First Middle Position Telephone Address City State Zip Last Name No. First Middle Position Telephone 2 American LegalNet, Inc. www.FormsWorkFlow.com Address City State Zip Please explain your previous investment experience with either the company or the salesperson who contacted you. Additionally, describe any personal relationships/dealings with the company or the salesperson. C. Questions About Your Investment: Yes No N/A If you used a broker, were investments in the account solicited, or recommended by the broker? Were trades made in your account without your authorization? Did you receive a prospectus, private placement memorandum, private offering memorandum, disclosure brochure, or any other disclosure document before making the investment? If a private investment opportunity, did you receive audited financial statements on the company? Did the person selling you the investment discuss the risks of the investment prior to purchase? Did you understand the risks of the investment? Do you feel the investment was in line with your investment goals? Did you have the financial ability to absorb the risk of the investment? Did you understand where your money was to be invested? If your investment was made from a brokerage account, did your account have a margin agreement? If you used a broker or investment adviser, did they have power of attorney or the authority to 3 American LegalNet, Inc. www.FormsWorkFlow.com enter transactions in your account? INFORMATION ABOUT INVESTMENT D. What did you purchase or invest in? (Examples: common stock, debenture, limited partnership interest, investment contract, fractional interests in an oil and gas lease). If available, include a copy of your most recent account statement. Date of Purchase Security No. of Shares Unit Price Total Price Date of Purchase Security No. of Shares Unit Price Total Price Date of Purchase Security No. of Shares Unit Price Total Price How was the amount paid: (lump sum, installments, other / check, cash, wire, other) Who received the payment from you? Did you pay by mail? To whom did you make your checks payable? (Please provide a copy of both sides of the check if possible) E. Did you sign or receive any type of contract? Where was it signed (city/county)? Were your securities delivered? Where are your securities held? If so, please enclose a copy. If your securities have been delivered to you by mail, please attach a copy of the cover letter attached to your securities. F. How did you learn of the investment? (Check more than one if applicable and enclose copies of pamphlets or advertisements if available.) 4 American LegalNet, Inc. www.FormsWorkFlow.com Personal visit Date Location Whom Telephone call Date From whom Where was the call received? Advertising pamphlet/sales letter Sent to you at what address/location (If available, please include a copy of the pamphlet or letter) Newspaper Name of paper Date (If available, include a copy of the newspaper advertisement.) G. Radio Name of station Date Television Name of station Date Group Sales Presentation Date of presentation Where was presentation held? Other (Please Specify) List others who were present when the offers or sales were made to you. Name Address Telephone Relationship to Complainant Name Address Telephone Relationship to Complainant Name Address Telephone Relationship to Complainant H. Who else do you know that invested with the company, corporation, or association? 5 American LegalNet, Inc. www.FormsWorkFlow.com Name Address Telephone Relationship to Complainant Name Address Telephone Relationship to Complainant Name Address Telephone Relationship to Complaina
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