Utah > Department Of Commerce > Blue Sky > Securities
Complaint Form CF-GEN - Utah
| Complaint Form Form. This is a Utah form and can be used in Securities Blue Sky Department Of Commerce . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
UTAH DEPARTMENT OF COMMERCE Division of Securities 160 East 300 South, 2nd Floor P.O. Box 146760 Salt Lake City, Utah 84114-6760 Phone: 801-530-6600 Fax: 801-530-6980 COMPLAINT FORM ______________________________________________________________________________ Information about This Form and the Utah Division of Securities 1. 2. You may type or print on this form, but please make your responses legible. It's important for you to fill ou t each block o f this form so that we can fully eva luate your complaint. If a particular block doesn't apply to your situation, please indicate so by placing an "N/A" (i.e., not applicable) in the appropriate space. If you need additional space fo r any of your responses, please use the continuation blocks provide on page 12 of this complaint form. Please attach copies of all documents relev ant to your complaint -- for example: cancelled checks (both sides), contracts, correspondence, prospectuses, sales brochures, etc. Your complaint will be confiden tial. Ho wever, be advised that under current Uta h law your complaint will be subject to releas e to members of the public under certain circumstances. If you have any questions about this matter, please contact the Division's Records Officer. When you have completed this form, please ma il it (along w ith any attachments) to: Utah Division of Securities, P .O. Box 146760, Salt Lake City, Utah 84114-6760. If you wish to contact the office by phone, our number is : (801) 530-6600. Our FAX number is (801) 530-6980. Our E-mail address is securities@utah.gov O ur office is open for inquires Monday th rough Thursday (except lega l holid ays), 7:00 a.m. to 6:0 0 p.m., Mo untain Standard Time. Please be advised that the Division will not act as your attorney for purposes of recovering a lost investment. Any person who has lost m oney as the victim of an unlawful securities transaction should immediately contact his or her personal attorney about the possibility of bringing a lawsuit to recover lost funds. If your case involves a violation of the Utah Uniform Securities Act, Utah Code Annotated §§ 61-1-1 et seq., as amended, you m ay be able to bring a lawsuit under § 22 of the Act. Under § 22, you may be able to recover your lost funds (with 12% interest) and reasonable attorney's fees. 3. 4. 5. 6. 7. American LegalNet, Inc. www.FormsWorkFlow.com BLOCK A: INFORMATION ABOUT YOU Block A(1) -- Your Name. ______________________________________________________________________________ Last Name First Name Middle Initial Block A(2) -- Your Home Address. ______________________________________________________________________________ Street Address City and State Zip Code Block A(3) -- Your Work Address. ______________________________________________________________________________ Street Address City and State Zip Code Block A(4) -- Your Phone Numbers and E-mail address. Home: ( Cell: ( ) ) Business: ( E-mail: ) Block A(5) Your Demographics. Please ch eck the applicable boxes for you a t the time you originally invested. Age Net Worth (exclusive of home) Net Income Tax Bracket 65 or Older 45 to 65 31 to 44 18 to 30 Business $0-50,000 $50,000-100,000 $100,000-250,000 $250,000-500,000 >$500,000 $0-20,000 $20,001-50,000 $50,001-100,000 $100,001-250,000 > $250,000 0% 15% 28% 36% 39.6% 2 American LegalNet, Inc. www.FormsWorkFlow.com BLOCK B: INFORMATION ABOUT YOUR INVESTMENT Block B(1) -- Nature of Your Investment. In your own words, briefly state what kind of an investment you bought or thought you were buying. For example: a sto ck; a bond; a note; an investment c ontract; a limited partn ership; an o il, gas, or mining title or lease; a commodity contract or commodity option, etc. If you're no t sure what kind of security (if any) you were offered, please state so . Plea se a lso sta te the dollar amount(s ) you invested and how many shares, items, units, etc., you bought or thought you were buying. 3 American LegalNet, Inc. www.FormsWorkFlow.com Block B(2) -- Company Name of Investment. Please provide the name of the company, brokerage firm, investment adviser, or issuer with which you invested. If payment was made to some other company name, this will be noted further below. ______________________________________________________________________________ Company Name Account Number Phone ______________________________________________________________________________ Street Address City and State Zip Code Block B(3) -- Payment For Investment. Please provide the am ounts and dates of your investment(s). Also, please note the form of payment by checking one of the following boxes. Cash Check Money order Wire transfer Trade Other Amount (in U.S. Dollars): $ ___________________ Amount (in U.S. Dollars): $ ___________________ Amount (in U.S. Dollars): $ ___________________ Amount (in U.S. Dollars): $ ___________________ Date: _________________ Date: _________________ Date: _________________ Date: _________________ Please identify any amount paid/returned to you in connection to this investment. This may be dividend, interest, return of capital, or profits. Amount (in U.S. Dollars): $ ___________________ Date: _________________ Block B(4) Person/Company Paid. Regardless of what information was entered on Block B(2) above, to whom did you make payment for your investment? Where was the address for any payments sent by mail and what was the bank information for any payments sent by wire. Also, if you have copies of the check(s), receipt(s), or wiring confirmation(s), please send those attached with this complaint form. 4 American LegalNet, Inc. www.FormsWorkFlow.com Block B(5) Questions About Your Investment. Answer the following account questions if the y apply to your situation: 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? 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 the risks of the investment? Did you understand wher
|
|||||||
