Please be advised that the Bureau does not have the specific authority to order restitution or the repayment of any monies which you may believe are due you.

1. Type of firm (if known): Securities Brokerage Firm Investment Advisory Firm Financial Planning Firm Other

If other, please specify:

2. Name and title of firm's agents or employees with whom you dealt:

Name:

Title: If known, type of professional designation used: Investment Adviser Stockbroker (Agent) Financial Planner Other
If other, please specify:

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Name:

Title:

If known, type of professional designation used: Investment Adviser Stockbroker (Agent) Financial Planner Other

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If other, please specify:

3. How was the initial solicitation made?

Telephone Seminar Other Internet

If other, please specify:

If the initial solicitation was made via the Internet, please specify URL/Web site/E-Mail address:

4. Type of investment product involved in your complaint:

Stocks Bonds Mutual Funds Limited Partnerships Other

If other, please specify:

5. Did you receive a prospectus when you purchased the investment?

Yes No

6. Have you contacted the firm about your complaint?

Yes No

If "YES," please provide the date contact was made, and the name and address of those you have contacted:

Name:

Street Address:

City: State:   ZIP Code: Date contact was made:

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Name:

Street Address:

City: State:   ZIP Code:

Date contact was made:

7. Have you contacted another regulatory or law enforcement agency about your complaint?

Yes No

If "YES," please provide the following information:

Name of Agency:

Name of person contacted:

Street Address of Agency:

City: State:   ZIP Code: Date contact was made:

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Name of Agency:

Name of person contacted:

Street Address of Agency:

City: State:   ZIP Code: Date contact was made:

8. Describe the facts of your complaint in the order in which they happened.

9. The amount of loss involved in the complaint $

10. The funds used for investment were originally drawn from:

Savings, Checking or Money Market Account Certificate of Deposit IRA/Retirement Account Insurance Proceeds Proceeds from another investment Other

If Other, please specify:

11. Investor's Age (optional)

Under 30 31-40 41-50

51-60 61-70 Over 70

12. Certification

I certify this complaint is true and correct to the best of my knowledge

Yes No

Please note that the answers on your complaint form will remain on the screen after you have submitted the form.
Please do not resubmit the form.