Official Federal Forms > FINRA
Claim Information Sheet - Official Federal Forms
| Claim Information Sheet Form. This is a national form and can be used in FINRA . |
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CLAIM INFORMATION SHEET I. PARTIES CLAIMANT(S):(Providethisinformationevenifyouarerepresentedbycounsel.) Name Address City DaytimeTelephone State Fax# ZipCode EmailAddress Residenceduringthetimeofthedispute(ifdifferentfromabove): Name Address City Claimantisa: Publiccustomer State ZipCode Broker-dealer Personassociatedwithabroker-dealer Ifyouchecked"Broker-dealer"or"Personassociatedwithabroker-dealer,"itisimportantthatyouprovidethe correctBD/CRDnumber.TodeterminewhetherapartyisaFINRAfirmorassociatedperson,youmayconsultFINRA's BrokerCheckprogramontheWebatwww.finra.org/BrokerCheck. BD# CRD# Claimant's Counsel/Representative (if applicable):(Note:FINRArequiresthatpersonsrepresentingFloridainvestorsin arbitrationproceedingsconductedinoroutsideoftheStateofFloridaaffirmeitherthattheyarelicensedtopracticelaw andprovideabaridentificationnumber,orthattheyarenotreceivingcompensationinconnectionwithrepresenting thepartyinthearbitrationproceeding.) Name Address City BusinessTelephone State Fax# If needed, copy this page to list additional claimants. ZipCode EmailAddress BarID#(ifapplicable) 14 American LegalNet, Inc. www.FormsWorkFlow.com CLAIM INFORMATION SHEET RESPONDENT(S) Respondent #1: Name Address(ifknown) City BusinessTelephone Respondent#1isa: Publiccustomer State Fax ZipCode EmailAddress Broker-dealer Personassociatedwithabroker-dealer Ifyouchecked"Broker-dealer"or"Personassociatedwithabroker-dealer,"itisimportantthatyouprovidethe correctBD/CRDnumber.TodeterminewhetherapartyisaFINRAfirmorassociatedperson,youmayconsultFINRA's BrokerCheckprogramontheWebatwww.finra.org/BrokerCheck. BD# CRD# Respondent #2: Name Address(ifknown) City BusinessTelephone Respondent#2isa: Publiccustomer State Fax# ZipCode EmailAddress Broker-dealer Personassociatedwithabroker-dealer Ifyouchecked"Broker-dealer"or"Personassociatedwithabroker-dealer,"itisimportantthatyouprovidethe correctBD/CRDnumber.TodeterminewhetherapartyisaFINRAfirmorassociatedperson,youmayconsultFINRA's BrokerCheckprogramontheWebatwww.finra.org/BrokerCheck. BD# CRD# If needed, copy this page to list additional respondents. 15 American LegalNet, Inc. www.FormsWorkFlow.com CLAIM INFORMATION SHEET II. CLAIMS Accounts:Ifthedisputeorclaiminvolvesactivitywithrespecttoanaccountoraccounts,pleaselisteachaccountand indicatethetypeofaccountitis(e.g.,jointaccount,custodialaccount,etc.) 1. Name(exactlyasitappearsontheaccount) NameofFirmandBranchOffice NameofRegisteredRepresentative 2. TypeofAccount DateAccountOpened Name(exactlyasitappearsontheaccount) NameofFirmandBranchOffice NameofRegisteredRepresentative 3. TypeofAccount DateAccountOpened Name(exactlyasitappearsontheaccount) NameofFirmandBranchOffice NameofRegisteredRepresentative TypeofAccount DateAccountOpened If needed, copy this page to list additional accounts. 16 American LegalNet, Inc. www.FormsWorkFlow.com CLAIM INFORMATION SHEET Type of Dispute: (Check where applicable) a. b. c. d. e. f. Account Related BreachofContract Collection Dividends Errors/Charges Executions ExecutionPrice FailuretoExecute Account Activity BreachofFiduciaryDuty Churning Manipulations Employment BreachofContract Commissions Compensation DiscriminationAge DiscriminationDisability DiscriminationGender Trading Dispute Buy-In D.K.s Manipulation Other ClearingDispute Defamation Indemnification RaidingDisputes Underwriting Other Markups SellOuts StockLoan Transfers Other DiscriminationNationalOrigin DiscriminationRace DiscriminationReligion DiscriminationSexualPreference LibelorSlander LibelorSlanderonFormU-5 Partnerships PromissoryNotes SexualHarassment TrainingContracts WrongfulTermination Other Misrepresentations OmissionofFacts Suitability UnauthorizedTrading Other IncorrectQuantity LimitVersusMarketOrder Other Exchanges FailuretoSupervise MarginCalls Negligence Transfer Other 17 American LegalNet, Inc. www.FormsWorkFlow.com g. Type of Security(ies), Financial Instrument(s), and/or Investment(s) involved in the Dispute: Annuities VariableAnnuities Auction-RateSecurities CertificatesofDeposit CollateralizedDebtObligations(CDOs) CollateralizedMortgageObligations(CMOs) Commodities(OtherthanFutures) CommonStock CorporateBonds Exchange-TradedFunds Other: "FannieMaes" "FreddieMacs" Futures "GinnieMaes" GovernmentSecurities HedgeFunds LimitedPartnerships MunicipalBonds MunicipalBondFunds MutualFunds Options PreferredStock PrivateEquities RealEstateInvestmentTrust RepurchaseAgreements ReverseConvertibles ReverseRepurchaseAgreements StockIndexFutures StructuredProducts Warrants/Rights 18 American LegalNet, Inc. www.FormsWorkFlow.com CLAIM INFORMATION SHEET III. 1. RELIEF REQUESTED Damages ActualDamages Requested (monetarysumrequiredtocompensateapartyfor hisorherlossexcludinginterestsandexpenses) $ 1. PunitiveDamages Requested (monetaryamountintendedtopunishthewrongdoer) * AMOUNTINDISPUTE: 2. 3. * Usethisamounttocalculatethecorrectfilingfee ndhearing a sessiondepositinPartIV.Thisamount ustmatchtheamount m statedinyourclaim. Interest (includecalculations,ifpossible) 2. Other Type of Relief Requested SpecificPerformance(Specifythetypeofspecificperformancesought) (specificperformancerequirespartiestotakeanaction,suchasturningoverownershipofstocks) InjunctiveRelief(Specifythetypeofinjunctivereliefsought) (injunctionsrequirepartiestorefrainfromcertainactions) 3. Costs (Providespecificamounts,ifknown.Ifnotknown,pleasemarkan"X"toindicatethecostsyouarerequesting) ForumFees Attorney'sFees WitnessandProductionFees OtherCase-RelatedCosts 4. Panel Selection Method for Customer Cases Decided by Three Arbitrators: IamrequestingtheOptionalAll-PublicPanelRuleforselectingarbitrators. IamrequestingtheMajority-PublicPanelRuleforselectingarbitrators. 19 American LegalNet, Inc. www.FormsWorkFlow.com CLAIM INFORMATION SHEET Customer or Associated Person Claimant IV. FEES TO DETERMINE THE CORRECT FEE, USE THE "AMOUNT IN DISPUTE" FIGURE ON LINE 3, PAGE 19. IfyouareaCUSTOMER OR ASSOCIATED PERSON CLAIMANTusethistable(Rule12900ofthe Customer CodeorRule13900 oftheIndustry Code)todeterminethefilingfeethatMUSTaccompanyaStatementofClaimwhenitisfiledwithFINRA. IfyourclaimdoesNOTdiscloseorspecifyamonetaryclaim,thefilingfeeis$1,250. Findtheamountofyourdisputeonthechart,thenfindtheapplicableclaimfilingfee. Filing Fees for Claims Filed by Customers, Associated Persons and Other Non-Members Amount of Claim (exclusiveofinterestandexpenses) $.01to$1,000 $1,000.01to$2,500 $2,500.01to$5,000 $5,000.01to$10,000 $10,000.01to$25,000 $25,000.01to$50,000 $50,000.01t
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