Complaint Form

INSTRUCTIONS FOR FILING A COMPLAINT How to file a complaint You can file a complaint with Securities Division by completing the attached complaint form and sending it, together with copies of the documents that support your claim to: Department of Financial Regulation Vermont Securities Division Attn: Investor Complaints 89 Main Street Montpelier, Vermont 05620-3101 Documents that you should send with completed complaint form include copies of: Letters E-mails Trade confirmations Pamphlets Offering circulars Prospectuses or written offering memoranda Purchase agreements Stock certificates Advertisements Any other materials that you may have that would help support your claim These items are not required in order to file a complaint, we simply ask that you provide them if you have them. PLEASE DO NOT SEND YOUR ORIGINAL DOCUMENTS, ONLY PHOTOCOPIES. What should I say in my complaint? The more information that you can provide, the more likely we will be able to promptly decide how we can help you. In order to assist you, it is very important that you provide us with the names, addresses, telephone numbers, and other identifying information concerning any person or entity that you mention in your complaint. It is equally important for you to provide us with the details of any transaction or activity you think violates the Vermont Uniform Securities Act. You should present the events in the order in which they occurred and use dates whenever possible. 1 of 8 Revised 11/07/2013 American LegalNet, Inc. www.FormsWorkFlow.com What will the Securities Division do with my complaint? Upon receipt of your complaint, we will file the complaint in the Securities Division's records and consider making an inquiry into the matter. You should be aware that the initial evaluation of your complaint might take several weeks. Moreover, it may take many months before the Division can make a final decision as to whether we should bring an enforcement action based upon your complaint. It is the Division's policy to conduct our inquiries on a confidential basis. This is done to protect the integrity of the investigation and to protect the personal privacy of persons to whom unfounded allegations may be made. You will usually receive a letter from the Division acknowledging our receipt of your complaint within a few weeks after we have received it. If, after reviewing your complaint, the Division determines that it would not be appropriate or in the public interest for us to pursue your complaint, you will receive follow-up letter to that effect. On the other hand, should the Division elect to pursue an enforcement action, you will be made aware of that fact once our intentions have been made public. In some instances, our actions may be resolved informally or through the issuance of an uncontested "Consent Order." Generally, informal actions are considered "non-public." Consent Orders, however, are a matter of public record. If you have additional questions concerning the complaint process, please telephone the Division at (802) 828-3420. Is there anything else that I should know about the complaint process? There are a few very important things that you should know about the complaint process: Your complaint and any related investigation information are generally not available for public inspection under the Vermont Public Records Act. While in most instances your complaint shall be treated as a confidential matter, the Securities Division may share a copy of your complaint with the person or firm about whom you have complained to further the Division's investigation and evaluation of your complaint. The Securities Division may share information about your complaint with other state and federal regulators and law enforcement agencies for the express purpose of assisting these agencies with the enforcement of state and federal laws. You should be aware, however, that federal agencies may not be able to fully protect all shared information from eventual public disclosure. Should the Securities Division begin a formal legal proceeding involving your complaint, your complaint and any related documents may become information available to the public through the Securities Division's legal filings and any hearing or trial that may result. 2 of 8 Revised 11/07/2013 American LegalNet, Inc. www.FormsWorkFlow.com - 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):____________________________________________ 5. Location(s) where the transaction(s) took place:______________________ _____________________________________________________________ 3 of 8 Revised 11/07/2013 American LegalNet, Inc. www.FormsWorkFlow.com 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? _____________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________