Missouri > Secretary Of State > Blue Sky > Securities
Information Sheet (Complaint) - Missouri
| Information Sheet (Complaint) Form. This is a Missouri form and can be used in Securities Blue Sky Secretary Of State . |
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STATE OF MISSOURI - OFFICE OF SECRETARY OF STATE MATT BLUNT SECRETARY OF STATE JEFFERSON CITY, MO, 65102 (573) 751-4704 Information Sheet Investor Information Your Name ____________________________________________ Date of Birth ___________ ________________ Address ________________________________________________________________ ______________________ City _____________________________________________ State ___________ Z ip _______________________ Telephone ( )________________________ Business Telephone ( )_______________________________ Company and Salesperson Information Company and Salesperson Information Name of Company_____________________________________________________________ ________________ Name of Salesperson_________________________________________________________________ __________ Address_________________________________________________________________ ____________________ City__________________________________________ State_______________ Zi p______________________ Telephone ( )_____________________________________________________ _________________________ Investment Information 1. Explain what you were offered: _________________________________________ _____________________ ________________________________________________________________________ ___________________ 2. How much money did you invest? _________________Payment was made by: ____ cash ____ check ____ other 3. Date of investment(s): ________________________________Place of Investment(s):___________________ <<<<<<<<<********>>>>>>>>>>>>> 24. Please give a brief explanation of how you gained knowledge of this investment and exactly what you were told about the investment. ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ a. What were you told your money would be used for? _______________________________________________ ________________________________________________________________________ _____________________ b. What amount of return were you promised?_______________________________________________________ c. What were you told about the risks of this investment? _____________________________________________ ________________________________________________________________________ ____________________ ________________________________________________________________________ ____________________ d. Did you receive a prospectus or other information regarding the financial condition of the company? ________________________________________________________________________ ____________________ e. Did the seller give you inform out to be untrue?ation that later turned__________________________________ If yes, please explain: ________________________________________________ ___________________________ ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ f. Did you sign a contract?________________________________________________ _____________________ 5. any other governmHave you contacted an attorney orent agency? _______________________________________ If yes,who?_____________________________________________________________ _____________________ 6. Have you asked for the return of your initial investment? ______________If so, did you receive it? ____________ <<<<<<<<<********>>>>>>>>>>>>> 37. Please provide the names, addresses, and telephone numbers of any other investor: ________________________________________________________________________ ___________________ Documents 8. Please attach copies of the following documents: stock certificates/bonds/investment certificates confirmations of purchases cancelled checks (front and back) contracts any correspondence or advertising relating to the investment Signature: _____________________________________________________ Printed name: _________________________________________________ Date: ____________________ If you are seeking the return of your invested funds, please consult with private counsel. The State cannot represent you or pursue your private claims in court. If you have any question about this form, please call the investor hotline at: 1 (800)-721-7996. Please mail all correspondence to: Office of the Secretary of State Securities Division P.O. Box 1276 600 West Main Street Jefferson City, Mo 65102 To file a complaint via the Internet: http://www.sos.mo.gov/securities/complaint.asp To send your complaint via e-mail: securi@sosmail.state.mo.us (If you file your complaint via the internet or via e-mail be sure and send the documents requested above.)
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