Commerce Division of Securities : Complaints  
 

COMPLAINT FORM




DIRECTIONS:

The information you provide on this form is valuable to the Division's investigation of your complaint. Please furnish specific and detailed information, answer all questions that are applicable to your situation, be clear and concise in your answers. Failure to provide complete information may delay the processing of your complaint.



PERSONAL INFORMATION:


Last Name: First Name:
Address:    
   
County:  
City: State:  Zip:   
Work Phone:   Home Phone:  
Occupation: Cell Phone:  
Email:


1. Who is your complaint against (name, address, telephone number)?

Name:  
Address:  
   
City: State:    Zip:  
Phone Number:  

2. Date and means of initial contact (i.e., newspaper ad, mail, telephone solicitation, referral, etc.) Who made the initial contact?

Date:
Means:
Who:

3. Full name of person who sold the investment to you.


4. Other names associated with the person who sold the investment to you, such as a brokerage firm, company, or other principals or associates, etc. Please include addresses and phone numbers.


5. The following information relates to the actual investment you made. Please provide complete and factual data (i.e., Name of Investment, Type of Investment (i.e., stocks, bonds, limited partnership interests, etc.), Date of Investment, Price Per Share, Number of Share or Interests Purchased, Total Purchase Price, and Total Amount Invested).

--- Example ---
Name: Price:
Type: Quantity:
Date Purchased: Total Price:


Investment Information Share Information
Name: Price:
Type: Quantity:
Date Purchased: Total Price:
Name: Price:
Type: Quantity:
Date Purchased: Total Price:
Name: Price:
Type: Quantity:
Date Purchased: Total Price:
Name: Price:
Type: Quantity:
Date Purchased: Total Price:
Name: Price:
Type: Quantity:
Date Purchased: Total Price:
TOTAL AMOUNT INVESTED:

  1. Where did this transaction take place? Who was present?

  2. Place:
    Who:
  3. How did you pay for this investment (i.e., cash, check, money order, wire transfer, etc.)?
  4. Briefly describe your investment experience.

6. What were you told that made you decide to invest, such as, the type of profits you might receive, how risky or safe the investment would be, information about the future value of your investment, etc.? Who told you this?

7. What were you told about how the company was going to use your funds?

8. Did you make the company/salesperson aware of your financial situation, investment objectives, and/or your risk tolerance? If you answered 'YES', what was said, to whom, and when?

9. How frequently were you in contact with the company and/or your salesperson? With whom were you in contact and what did you discuss?

10. Were you encouraged to invest more money in the same or similar investment? If so, what was said to you, by whom, and when?

   

11. Specifically, describe your complaint:

12. Keeping in mind that the Division cannot act as private legal counsel on your behalf, how would you like your complaint to be resolved ? Please be specific.

13. Describe any contacts you have had with the company and/or your salesperson concerning your complaint? Please forward copies of any correspondence and other documents between you and the company and/or your salesperson.

14. Have you contacted any other agency regarding your complaint? If you answered 'YES', please furnish the name of the agency, when filed, and status (if known).

 
 

15. Have you contacted a private attorney about this matter? If you answered 'YES', please include the attorney's name, address, and telephone number.

   
   
 
   
     
     

16. If you are aware of anyone else who has made a similar investment, please provide names and addresses.

17. Additional comments or information.

Documentary evidence is especially important. Please forward copies, not originals, of the front and back of your canceled checks, confirmations, statements, correspondence, certificates, prospectus, and any other written materials pertaining to your complaint. Please send this information to:

Ohio Division of Securities
77 South High Street, 22nd Floor
Columbus, Ohio 43215
ATTN: Enforcement

Your complaint will remain confidential under R.C. 1707.12. It is a criminal offense and a violation of R.C. 2921.13(A) to make a false statement for the purpose of misleading a public official.