Complaint Form – Alabama Securities Commission

STATE NAME AND ADDRESS OF FIRM OR PERSON COMPLAINT IS AGAINST:

Name:*

Address:

City:

State:

Zip Code:

Phone Number:

Email:

STATE YOUR NAME AND ADDRESS:

Name:*

Address:*

City:*

State:*

Zip Code:*

Home Phone Number:*

Work Phone Number:

Email:

TYPE OF COMPLAINT:

Complaint against a Company or FirmNoYes

Complaint against an IndividualNoYes

Other, Please Specify:

Approximate Date of Transaction:*

Place of Transaction (Specify the States in which you and the salesman were located)*

Witnesses to the Transaction:

State the type of investment involved (e.g. stock, note, limited partnership, etc.)

If you invested in stock or bonds, what was the name of the issuing corporation?

If you invested in a note, who was the maker (Company or Individual) responsible for paying it?

If you invested in a partnership, what was the name of that partnership?

Other:

Amount involved in transaction: (The $ is not recommended)*

Do you have and can you provide evidence of investment (front and back of checks; cashiers checks; money orders; etc.)?*NoYes

Did you sign any papers or documents?*NoYes

(If Yes, please attach copies of them.)

How did you first learn about this investment?

Have you complained to the Company or Firm?*NoYes

(If yes, to whom?)

What was the response?

May we send a copy of your complaint to the firm or individual complained against?*NoYes

Does an attorney represent you in this matter?*NoYes

If YES, give Attorney’s Name and Address:

Name:

Address:

City:

State:

Zip Code:

Did you begin any legal action against this company?NoYes

(Explain)

Are you willing to sign an affidavit or testify regarding your transaction with this Company?*NoYes

Specify other governmental or regulatory agencies contacted:

May we send a copy of your complaint to another governmental agency or regulatory body for their review or investigation?NoYes

Did you tape-record any of your conversations regarding the transaction(s)?NoYes

Names, telephone numbers and/or addresses of any other known investors:

Please explain the entire circumstances surrounding your complaint in the space provided below. It is important to include all details about the transaction, no matter how unimportant you may think they are. Please be specific in referring to any names, dates or documents. Also, if any part of the transaction occurred outside of Alabama, please indicate that fact. Remember that it is better to include too much information, rather than too little information. Be sure to describe the type of investment and any instruments you received evidencing you investment.*

CONFIRMATIONThe above is true and accurate to the best of my knowledge.