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Complaint Report (Investor) - Washington
| Complaint Report (Investor) Form. This is a Washington form and can be used in Securities Blue Sky Secretary Of State . |
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Securities Division PO Box 9033 Olympia WA 98507-9033 360-902-8760 Fax: 360-586-5068 Complaint Report Please print or type: Investor Information Your Name ______________________________________________ Birth Date ____ __________ Address ________________________________________________________________ _______ City _____________________________ State _______________ Zip Code ______ ___________ Phone (day) _____________________ (eve) ___________________ Best tim e to call _________ E-mail Address ____________________________________ Occupation ________ ___________ Complaint Against Name of business ______________________________________________________ _________ Person you dealt with __________________________________________________ ___________ Address ________________________________________________________________ _______ City _____________________________ State ________________ Zip Code _____ ___________ Phone ________________________ Cell phone (if any) __________________ ____ Business E-mail or Web Site Address ____________________________________ ____________ Names, Addresses, and phone numbers of any other businesses, or persons involved in your complaint: _________________________________________________________________________ _____ ________________________________________________________________________ ______ ________________________________________________________________________ ______ Revised 10/31/02 <<<<<<<<<********>>>>>>>>>>>>> 2 Your Complaint How and when did you first hear about this investment? ________________________________________________________________________ ______ ________________________________________________________________________ ______ How much money did you invest? _________________________________________ __________ What date(s)? _______________________________________________________ ___________ What kind of investment(s) did you buy? ______________________________ ________________ ________________________________________________________________________ ______ ________________________________________________________________________ ______ How did you pay for your investment(s) (e.g., personal or cashiers check, cash, wire transfer, etc.)? ________________________________________________________________________ ______ What method did you use to deliver the payment (e.g., in person, mail, fed ex, etc.)? ________________________________________________________________________ ______ How and when did the person first contact you? _________________________ _______________ ________________________________________________________________________ ______ Please list any courier or postal service used by the person to contact you and when that contact occurred: ________________________________________________________________________ ______ Have you complained to the person or firm? If yes, please describe. Was your complaint in writing, or did you speak to someone? If in writing, please send a copy of the complaint. If you spoke with a person, who was it and when did it happen? ________________________________________________________________________ ______ ________________________________________________________________________ ______ Have you contacted any other regulator or taken any legal action? If yes, please describe. ________________________________________________________________________ ______ ________________________________________________________________________ ______ Revised 10/31/02 <<<<<<<<<********>>>>>>>>>>>>> 3 Explain your complaint in detail Please provide a detailed explanation of the facts that led to your complaint. Start at the beginning and continue through to the present. Be sure to include AT LEAST the following information: How, when, and from whom did you first hear about this investment? What verbal and/or written information did you receive abou t the investment? Did you later find that any of this information was untrue? (Use additional pages if necessary and attach to this report) Revised 10/31/02 <<<<<<<<<********>>>>>>>>>>>>> 4 Documents Please attach copies of any documents or written materials relating to your complaint, including the front and back of any checks you used to pay for your investment(s). If your complaint involves brokerage accounts, please make copies of the brokerage statements showing the transaction(s). We will ask for the original documents if we need them. If you send any materials you want returned, please indicate what you want returned below- ________________________________________________________________________ ______ ________________________________________________________________________ ______ Request for Nondisclosure under the Public Records Disclosure Act Under the public records provisions of Washington law, RCW 42.17 et seq., this complaint may become subject to public disclosure after the investigation is ended. By checking the box, I request this complaint not be disclosed if it is requested pursuant to the Public Records Disclosure Act. Other Investors Do you know anyone else who purchased the investment that is the subject of this complaint? If so, please list their names, addresses, phone numbers. ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ Jurisdiction of the Securities Division The jurisdiction of the Securities Division generally extends only to issues connected with the initial offer and sale of securities, franchises, business opportunities, and commodities. We may not have jurisdiction if your complaint involves later actions by management that you think are unfair to investors, or in actions by management such as the failure to hold shareholder meetings or provide annual reports. However, you may have civil remedies available to address your complaint, so please consult your attorney. Also, the Division does not have the authority to represent you in civil litigation, which means you must hire your own attorney to recover your investment funds. Signature In filing this signed and dated complaint form with the Securities Division, I am stating that the information provided is true and correct to the best of my knowledge and that the information may be used to further investigate my complaint. __________________________________________________ __________________ _____
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