Investor Protection Bureau Complaint Form Info If your complaint involves a franchise purchase, please visit our franchise disputes page. Your information First name Middle name Last name Address line 1 Address line 2 City/town State - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP (ex:12345 or 12345-1234) Home phone (ex:999-999-9999 or 999-999-9999 x9999) Business phone (ex:999-999-9999 or 999-999-9999 x9999) Mobile phone (ex:999-999-9999) Email address Company or person you are complaining about Company name Salesperson's name Address line 1 Address line 2 City/town State - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP (ex:12345 or 12345-1234) Phone (ex:999-999-9999 or 999-999-9999 x9999) Email address URL Complaint details Date of transaction Nature of investment Total amount of investment Did you receive the security you purchased? Yes No Please describe your complaint fully. If you prefer, attach a document describing your complaint. What relief are you seeking? What actions have you taken so far? Have you complained to the company or individual? Yes No Date of complaint What was the company or individual’s response, if any? Name and title(s) of individual(s) to whom you complained Has this matter been submitted to another agency or an attorney? Yes No Agency or attorney name Address line 1 Address line 2 City/town State - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Phone (ex:999-999-9999 or 999-999-9999 x9999) Email address Submission date Is court action pending? Yes No Court venue name Court date Do you have any supporting documents? Yes No We suggest removing social security numbers, date of birth, and account numbers unless needed to understand your complaint. Maximum 10 files.100 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. In filing this complaint, I understand that: The Attorney General is not my private lawyer. The Attorney General is a public servant who protects the public from illegal or misleading practices. This complaint does not mean that the Attorney General will start a lawsuit for me. The Attorney General cannot give me legal advice or represent me in court. If I have any questions about my legal rights or responsibilities, I should contact a private lawyer. The Attorney General may send a copy of my complaint, and any documents I provide, to the person or organization I mention in my complaint. I give that person or organization permission to provide information about my complaint to the Attorney General. The Attorney General may use information from my complaint to show that the law has been broken. The Attorney General works with other government agencies at the state, local, and federal levels to investigate complaints and work with the police. The Attorney General may share my complaint with these agencies. My complaint is true and accurate, as far as I know. Any false statements I have made in this complaint can be punished as a Class A misdemeanor (under Penal law Section 175.30 or Section 210.45, or both). By signing or typing my full name below, I certify that the above complaint is true and accurate to the best of my knowledge and that any documents attached are true and accurate copies of the originals. Signature Date
