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Complaint Form - Securities Bureau CF - Nebraska
| Complaint Form - Securities Bureau Form. This is a Nebraska form and can be used in General Blue Sky Secretary Of State . |
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COMPLAINT FORM Securities Bureau PLEASE PRINT THIS FORM, COMPLETE IT, SIGN IT, AND RETURN IT BY MAIL TO: Nebraska Department of Banking & Finance Securities Bureau - Complaints P.O. Box 95006 Lincoln, Nebraska 68509-5006 GUIDELINES FOR COMPLETING THE COMPLAINT FORM This form is to be printed off and completed. Before filling it out, ple ase take the time to read these guidelines; they will help you understand our functions so that we , in turn, can serve you better. WHAT WE CAN DO We investigate complaints against individuals, business entities, and co rporations 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 violati ons, and, in appropriate cases, to refer matters to the proper authorities for further investigat ion and/or criminal prosecution. Please refer to the Securities Bureau Page for types of ent ities regulated by the Department. We investigate complaints for alleged violations of the following laws: Nebraska Commodity Code, Securities Act of Nebraska, Loan Brokers Act, Seller-Assisted Mark eting Plan Act, Consumer Rental-Purchase Agreement Act WHAT WE CANNOT DO We cannot act as a court of law to resolve factual disputes. We cannot order monies be refunded, contracts be cancelled, damages be awarded, etc. If you have t his type of problem, you should consult a private attorney. We cannot give legal advice or ac t as your attorney. Please fill out the form by typing or printing clearly in ink. Sign the form and return it to the address above. Keep a copy for your files. Rev. 4-98 1 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 SECTION I - CONSUMER INFORMATION Your name: (Last, First, MI) Your daytime phone: (include area code) Your street address: (if different from mailing address, please note) City: State: Zip code: SECTION II - COMPANY/INDIVIDUAL INFORMATION Name of the company/individual: Business address: Business phone: (include area code) City: State: Zip code: Rev. 4-98 2 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3 SECTION III - NATURE OF THE PROBLEM Briefly describe the nature of your complaint and the events in the orde r in which they happened, including specific dates, and the companys/individuals actio ns to which you objected. Enclose COPIES of any pertinent information or correspondence that may be helpful. DO NOT SEND ORIGINALS; DO NOT SEND YOUR ONLY COPY OF ANY DOCUMENT. Keep a copy of this response for your own files. (If additional space is needed, please attach a separate sheet and reference it accordingly.) Have you attempted to resolve your complaint directly with the company/i ndividual? Yes No Name of person(s) contacted: Date(s) contacted: Companys/individuals response: (If additional space is needed, please attach a separate sheet, and reference it accordingly.) Rev. 4-98 3 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 4 PRIVACY STATEMENT The information requested on this form will be used to investigate and r espond to your complaint. In our efforts to resolve your issue, this information may be disclosed outside of our agency to the company/individual which is the subject of your compla int; to any involved third parties; to the federal agency that has supervisory autho rity over the company/individual; to appropriate federal, state or local law enforceme nt authorities if a violation or possible violation of civil or criminal law is discovered; or to a legislative office in response to any inquiry made at your request. DISCLOSURE I wish to file a complaint against the company/individual named in this complaint form, with the understanding that the Bureau may conduct an investigation in m y behalf. However, I understand that the Bureau does not have the authority to act as a judge in factual disputes. I understand that completion of this form is voluntary , but failure to provide requested information and/or failure to sign this form may delay or preclude investigation of my complaint. I understand that, as a part of the inves tigation on my behalf, a copy of this form may be forwarded to the company/individual m entioned in the complaint. Signature Date: (required): Rev. 4-98 4 American LegalNet, Inc. www.USCourtForms.com
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