Vermont > Secretary Of State > Blue Sky > Securities
Complaint Form - Vermont
| Complaint Form Form. This is a Vermont form and can be used in Securities Blue Sky Secretary Of State . |
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Vermont Department of Banking, Insurance, Securities and Health Care Administration SECURITIES DIVISION COMPLAINT FORM 1. Your name:___________________________________________________ Street address:_________________________________________________ City, State and Zip:_____________________________________________ Home Phone:__________________ Work Phone:___________________ E-mail address:________________________________________________ 2. Name of firm(s) and/or individual(s) complained against: _____________________________________________________________ _____________________________________________________________ Street address:_________________________________________________ City, State and Zip:_____________________________________________ Phone:________________________ 3. Type of investment(s) involved (please select all that apply): Stock____ Bond____ Viatical Settlement____ Promissory Note____ Mutual Fund____ Variable Annuity____ Other____ (please describe): _____________________________________________________________ 4. Transaction date(s):____________________________________________ Revised 10/18/06 American LegalNet, Inc. www.FormsWorkflow.com 5. Location(s) where the transaction(s) took place:______________________ _____________________________________________________________ 6. Was anyone else present with you at the time of the transaction(s)? Yes____ No____ If "Yes," please provide his/her name and contact information: __________________________________________________ _____________________________________________________________ 7. Amount of money involved in the transaction(s):_____________________ _____________________________________________________________ 8. Did you sign or receive any documents? Yes____ No____ (If "Yes," please attach copies of the documents) 9. How and when did you first learn about the investment identified in item 3? _____________________________________________________________ ______________________________________________________________ 10. Have you complained to the firm(s) or individual(s)? Yes____ No____ If "Yes," when and to whom?_____________________________________ ______________________________________________________________ 11. Have you contacted any other governmental or regulatory agency? Yes____ No____ If "Yes," please provide the name and address of the agency and the name of the person handling your complaint:_____________________________ _____________________________________________________________ Revised 10/18/06 American LegalNet, Inc. www.FormsWorkflow.com 12. Please provide the name, telephone number and/or address of any other investor(s) that you are aware of: ______________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 13. Is an attorney representing you in this matter? Yes____ No____ If "Yes," please provide your attorney's name and address:_____________ _____________________________________________________________ _____________________________________________________________ 14. What were you told about the investment identified in item 3 and what were your expectations?__________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Do you believe that anything you were told about the investment was false or inaccurate and, if so, why?__________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Revised 10/18/06 American LegalNet, Inc. www.FormsWorkflow.com 15. Did you discuss your investment objectives and the amount of risk that was acceptable to you before you made the investment? Yes____ No____ If "Yes," please provide the name of the person with whom you spoke and the date that you spoke: _____________________________________ ____________________________________________________________ What were your investment objectives at the times of this investment? ____________________________________________________________ ____________________________________________________________ What was your risk tolerance at the time of this investment? ____________________________________________________________ ____________________________________________________________ 16. Please explain the circumstances surrounding your complaint. If you need more space, please attach additional sheets of paper. It is important to include as many details about the transaction(s) as possible, regardless of how insignificant those details may seem to be. Please be as specific as possible._________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ __________________________
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