Michigan > Secretary Of State > Blue Sky > Securities > Enforcement
Securities Complaint Form FIS-0500 - Michigan
| Securities Complaint Form Form. This is a Michigan form and can be used in Enforcement Securities Blue Sky Secretary Of State . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
FIS 0500 (5/02) Michigan Office of Financial & Insurance Services Consumer Services Division Securities Complaint Form COMPLAINANT INFORMATION (identifies you as the Compla inant) _____________________________________________________________________________________ Your Last Name First Middle Initial _____________________________________________________________________________________ Residence Address (Street, City, State and Zip Code) _____________________________________________________________________________________ Business Address (Street, City, State and Zip Code) _____________________________________________________________________________________ Occupation Business Telephone Number Residence Telephone Number I DECLARE I HAVE A COMPLAINT AGAINST: _____________________________________________________________________________________ Name of Business, Company, Firm, Person ______________________________________________________________________________________________________ Street address of Business (room number, suite number, or apartment number, if any) ______________________________________________________________________________________________________ City State Zip Code Business Telephone Number How and when did you first hear of the investment opportunity (e.g. advertisement in Wall Street Journal, telephone solicitation or Internet contact). ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Full names of salesperson, agent or other representative and/or names of any principals of the business entity. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ "This form is issued under Section 407, Act 265, PA 1964, as amended." <<<<<<<<<********>>>>>>>>>>>>> 2 Please explain the type of investment (i.e., stock, bonds, limited partnership, note, viatical settlement, contract, etc.) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Place(s) where transaction(s) occurred. Amount(s) Invested _____________________________________________________________________________________ _____________________________________________________________________________________ Have you contacted the business or person regarding your complaint? Yes No If yes, person(s) contacted _______________________________________________________________ Results of contact: ______________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Have you filed this complaint with another law enforcement or consumer protection agency? ___________ _____________________________________________________________________________________ _____________________________________________________________________________________ Are you willing to appear as a witness, be sworn, testify and be cross-examined concerning the allegations made in this complaint? Yes No If no, state the reason: __________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Please estimate your net worth including autos and house. $10,000 - 25,000 $50,000 100,000 $150,000 200,000 $25,000 50,000 $100,000 150,000 $200,000 or more <<<<<<<<<********>>>>>>>>>>>>> 3 Please explain in detail your previous investment experience. Indicates types of investments, amount invested and dates invested. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Did you rely on the business or financial experience of someone other than yourself? Yes No If yes, who? Please give details: __________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Please check below which of the following documents are attached or available to incorporate as part of this complaint. Attached Availabl e Type of Docum ent ________ ________ Advertising materials ________ ________ Agreement/Contract ________ ________ Promissory Note (if applicable) ________ ________ Cash Receipt(s) ________ ________ Cancelled Check(s) (front and back) ________ ________ Brochures/Prospectuses ________ ________ Copies of all documents which relate to your complaint and which are not listed above. List the names, addresses and phone numbers of other individuals who may have invested, or may have further knowledge of the investment. _____________________________________________________________________________________ _____________________________________________________________________________________ <<<<<<<<<********>>>>>>>>>>>>> 4 In a brief statement tell us the full story beginning with the date of the first contact to present. Keep dates of events in sequence and include misrepresentations. (Refer to Guidelines on pages 1 and 2). Include full names of all witnesses present during the transaction(s). Be factual. Keep in mind Who, What, Where and When. Attach extra sheets if necessary. _____________________________________________________________
|
|||||||
