Tips, Complaints and Referral Database-Pilot Phase

Proposed Data Fields

General Public

Are you employed as a financial industry professional?



Yes

No

Are you an External Partner, Self-Regulatory Organization (SRO), or other regulatory authority?



Yes

No

Select the profession that best represents you:

Accountant

Analyst

Attorney

Auditor

Broker-dealer

Compliance officer

Financial planner

Fund manager

Investment adviser

Investment adviser representative

Investment company director, officer, or employee

Registered representative

Transfer agent

Underwriter

Other – Specify [Textbox]

Are you complaining about an individual, a firm, or a market event or condition?

Individual

Firm

Individual and Firm

Multiple Individuals and/or Multiple Firms

Market Event or Condition

Select the title that best describes the Individual:

Accountant

Analyst

Attorney

Auditor

Broker

Compliance officer

Employee

Executive officer or director

Financial planner

Fund manager

Investment adviser representative

Receiver

Stock promoter

Trustee

Unknown

Other – Specify [ Textbox ]

Individual’s Title:

Mr. Mrs. Ms.

First Name: [ Textbox ]

Middle Name: [ Textbox ]

Last Name: [ Textbox ]

Street Address: [ Textbox ]

Address (Continued): [ Textbox ]

City: [ Textbox ]

State / Province: [ State / Province Dropdown List ]

Zip / Postal Code: [ Textbox ]

Country: [ Country Dropdown List ]

Telephone:

Home [ Telephone Number Format]

Work [ Telephone Number Format]

Mobile [ Telephone Number Format]

Other [ Telephone Number Format]

Email Address: [ Textbox ]

Where is the Individual that you are complaining about employed?

[ Textbox ]

Unknown

Select the term that best describes the Firm that is the subject of your complaint::

Bank

Broker-dealer

Clearing agency

Day trading firm

Exchange

FINRA

Insurance company

Investment adviser

Investment adviser representative

Investment company

IRA or 401(k) custodian/administrator

Market maker

Municipal securities dealer

Mutual fund

Newsletter company/investment publication company

On-line trading firm

Private fund company (including hedge fund, private equity fund, venture capital fund or real estate fund)

Private/closely held company

Publicly held company

Transfer agent/paying agent/registrar

Underwriter

Unknown

Other – Specify [Textbox ]]

Street Address: [ Textbox ]

Address (Continued): [ Textbox ]

City: [ Textbox ]

State / Province: [ State / Province Dropdown List ]

Zip / Postal Code: [ Textbox ]

Country: [ Country Dropdown List ]

Telephone Number: [ Textbox ]

Website: [ Textbox ]

If known, select the company or firm’s identifier:

Identifier Type

Ticker Symbol

CIK

Unknown

Ticker Symbol

Ticker Symbol [ Ticker Symbol Dropdown or Smart Look-Up ]

CIK [ Textbox ] Manual entry but future dropdown if database is available.

Other Information:

Are you or were you associated with the Individual or Firm when the alleged misconduct occurred?

Yes

No

Unknown

How is the Individual or Firm related to you? Presented if answered Yes above)

Accountant

Agent

Auditor

Attorney

Banker

Broker-dealer

Competitor

Controller

Current director or officer

Former director or officer

Current contractual relationship (contractor, consultant, vendor, supplier)

Prior contractual relationship (contractor, consultant, vendor, supplier)

Customer / client

Current Employee-specify role [Textbox]

Former Employee-specify role [Textbox]

Investment adviser

Investment adviser representative

Investor

Stock promoter

Prospective customer

Registered Representative

Significant security holder/ control person

Spouse, ex-spouse or other family member

Transfer agent

No relationship

Unknown

Other – specify [ Textbox ]

Allegation- additional fields are displayed based on [complaint subjects]

What is the nature of your complaint?

Are you complaining about a fraudulent investment scheme such as a ponzi scheme or the promise of high-yield returns? [Offering Fraud]

Does your complaint involve improper trading of a specific security, insider trading or manipulation of a security’s price or volume? [Securities Fraud]

Does your complaint allege theft or misappropriation of your funds or securities? [Theft / Misappropriation]

Are you complaining about an unregistered securities offering or an unregistered financial professional? [Registration]

Do you have a complaint about general trading practices, pricing issues or a specific market event? [Trading]

Are you complaining about the fees or commissions you were charged? [Fees / Mark-Ups / Commissions]

Do you have problems regarding your financial professional’s handling of your investments? [Sales and Advisory Practices]

Does your complaint relate to paperwork regarding your investments, delivery of funds or securities, or payment? [Operational Issues]

Are you having difficulty opening or closing your brokerage account or redeeming or transferring your mutual funds? [Customer Accounts]

Did your financial professional make misrepresentations about an investment product? [Misrepresentation / Omission (Non-Issuer])

Does your complaint relate to a company’s or a municipality’s disclosures, transactions or governance? [Corporate Disclosure and Issuer-Related Problems]

Do you wish to submit a complaint about the SEC or another securities regulator? [Complaints about SEC, SRO, and SIPC Processes & Programs

If your complaint does not fit in any of the categories above, please explain here:

Explain Allegation [Textbox]

Securities Fraud

Pump and dump scheme

Front running

Insider trading

Abusive naked short selling

Manipulation of a security’s price or volume

Suspicious end of day trading

Other

Specify Other [Textbox]

Theft / Misappropriation

Advance fee fraud

Theft of funds or securities by financial professional

Theft/forgery by other than financial professional

Identity theft/hacking of firm

Identity theft/hacking of individual

Misrepresentation / Omission (Non- Issuer)

False/misleading marketing/sales literature

Inaccurate, misleading, or non-disclosure by Broker-Dealers,

Investment Advisers and Associated Persons

False/material misstatements in firm research that were the

basis of transaction

Offering Fraud

Affinity fraud

Ponzi / pyramid scheme

High-yield investment

Other [Textbox ]

If a return on investment of any amount was guaranteed, what percentage was guaranteed?

[ % ] Enter Percentage

Unknown

If you are alleging offering fraud, how was the offer made?

Public filing with the SEC

Public filing made with other agency

Private placement documents

Non-personal message (radio, television, periodical, tout sheet, website)

Personal message (email, voicemail, phone call)

Other [Textbox ]

Unknown

Registration

Unregistered securities offering

Unregistered securities or advisory firm

Unregistered securities salesperson

Trading

After hours trading

Algorithmic trading/high frequency trading

Bankrupt companies, trading in

Market maker activities

Pricing Information: inaccurate quotes/pricing information

Specific market events or conditions

Trade execution

Other [Textbox ]

Fees / Mark-Ups / Commissions

Administrative fees: excessive or unnecessary

Breakpoints: failure to disclose

Commission or sales fees: excessive

Failure to disclose fees before transaction

Insufficient notice of change in fees

Negotiated fee problems

Fees / Mark-Ups / Commissions (cont.)

Mark-ups/markdowns: excessive

Spreads: excessive or otherwise improper

Corporate Disclosure and Issuer Related Problems

Audit

Bribery of, or improper payments to, foreign officials

Corporate governance

Conflicts of interest by management

Executive compensation

Failure to file material event notice concerning a municipal offering/issue

Failure to notify shareholders of corporate events

False/misleading financial statements

False/misleading offering documents

False/misleading press release

False/misleading proxy materials

Failure to file reports

Going private transactions

Kickbacks or improper payments to municipal issuers

Kickbacks or improper payments to pension associates

Mergers and acquisitions

Proxy materials/prospectus

Reverse stock splits

Selective disclosure – Regulation FD

Shareholder proposals

Tender offers

Sales and Advisory PracticeBreach of fiduciary duty/responsibility

Churning/excessive trading

Cold calling harassment

Cold calling: failure to comply with “do not call” list

Conflict of interest

Discretionary trading: abuse of authority

Failure to supervise

Guarantee against loss/promise to buy back shares

High pressure sales techniques

Inability to access funds or securities

Instructions by client not followed

Investment objectives not followed

Margin: inadequate disclosure or understanding or risks or procedures

Poor investment advice

Regulation S-P: privacy issues

Solicitation methods (non-cold calling): seminars

Suitability

Unauthorized transactions

Firm Operational Issues and Internal Control

Bond default

Confirmations/statements

Delivery of funds/proceeds

Dividend and interest problems

Firm Operational Issues and Internal Controls (cont)

Exchanges/switches of mutual funds with fund family

Lost or stolen securities

Margin: discrimination problem – Equal Credit Opportunity Act (Regulation B)

Margin: illegal extension of margin credit

Margin: Regulation T restrictions

Margin: unauthorized margin transactions

Online issues (trading system operation slowly or inaccessible)

Settlement

Stock certificates: old/lost

Tax reporting problems

Titling securities: difficulties titling ownership

Trade execution

Customer Accounts

Please select the category that best describes your complaint:

Abandoned or inactive accounts

Account administration and processing: matters relating to daily activity in an account

Account administration and processing: account opening

Account administration and processing: account closing and redemption issues

Identify theft affecting account

IPOs: problems with IPO allocation or eligibility

Inaccurate valuation of NAV

Transfer of account

Arbitration: bias by arbitrators/forum

Arbitration: failure to pay/comply with award

Arbitration: mandatory arbitration requirements

Arbitration: procedural problems or delays

SRO: failure to take action

SIPC proceedings and BD liquidations

Are you having or have you had difficulty in getting access to your funds/securities?

Yes

No

Unknown

Are you having or have you had difficulty in contacting the firm?

Yes

No

Unknown

If you suffered a loss, what is the amount of the alleged loss?

[ $ 0 ] Whole Dollars, no Decimals

Unknown

When did you become aware of the alleged misconduct?

[ Year, Month, Day, Date Dropdown ]

When did the alleged conduct begin?

[ Year, Month, Day, Date Dropdown ]

Unknown

Is the alleged conduct ongoing?

Yes

No

Unknown

When did the alleged conduct stop?

[ Year, Month, Day, Date Dropdown ]

Unknown

Has the individual or firm acknowledged the misconduct / error / deficiency?

Yes

No

Unknown

What is the source of your information? You may select more than one.

Account Statements

Broker Dealer Records

Conversations

Inside information

Publicly available information

SEC filings

Social media (e.g., blogs, chat rooms and electronic communities of interest)

Stock tip sheet or newsletter

Have you taken any action regarding your complaint? You may select more than one.

Complained to firm – specify [Textbox]

Complained to other regulator – specify [Textbox]

Complained to SEC – specify [Textbox]

Complained to law enforcement – specify [Textbox]

Complained to other – specify [Textbox]

Legal action

Mediation

Arbitration

Unknown

None

Other – specify [ Textbox ]

Tell us more about your allegation: [ Textbox ]

Provide supporting documentation, if any about your allegation:

Add Attachments

Are you declaring whistleblower status under Section 21F of the Investor Protection Act?

Yes

No

Are you represented by an attorney with respect to your complaint?

Yes

No

Please provide contact information of the attorney:

Name [Textbox]

Home [ Telephone Number Format]

Work [ Telephone Number Format]

Mobile [ Telephone Number Format]

Other [ Telephone Number Format]

Email [Textbox]

Would you prefer we contact your attorney or contact you directly?

Contact attorney

Contact me directly

Products

Select the type of security product t: You may select multiple products.

1031 exchanges

529 plans

ADRs

Annuities

Annuities: equity-indexed annuities

Annuities: fixed annuities

Annuities: variable annuities

Asset-backed securities

Auction rate securities

Banking products, including credit cards

Business development company

Certificates of deposit

Closed-end funds

Coins and precious metals (gold, silver, etc.)

Collateralized mortgage obligations (CMOs)

Commercial paper

Commodities

Commodities: currency transactions

Commodities: futures

Commodities: stock index options

Convertible securities

Debt

Debt: corporate (other than ABS, CMOs)

Debt: lower-rated or “junk”

Debt: municipal

Equities

Equities: exchange-traded

Equities: foreign (not ADRs)

Equities: OTC

Equities: unregistered

Equities: linked notes

ETFs

Franchises and other business ventures

Hedge Funds

Insurance contracts (not annuities)

Money-Market funds

Mortgage-backed securities

Mortgages

Mortgages: reverse mortgages

Mutual Funds

No Product/ Product not mentioned

Options

Options: commodity options

Options: index options

Partnerships

Preferred shares

Prime bank securities/high yield programs

Promissory notes

Real estate

Real estate investment trusts (REITs)

Retirement Plans

Retirement Plans: 401(ks)

Retirement Plans: IRAs

Retirement Plans: Public Pensions

Rights and warrants

Structured note products

Subprime issues

Treasury securities

U.S. government agency securities

Unit investment trusts (UITs)

Viaticals and life settlements

Wrap accounts and SMAs

Other – Specify [Textbox ]

Unknown

Enter the CUSIP number:

[ Textbox ]9 character alphanumeric validation

Unknown

Enter the security/ticker symbol:

[ Textbox ] Dropdown Smart Look-up

Unknown

Confirm or enter the product name:

If possible, system should derive and pre-populate field from user entries

Confirm [Pre-populated field ]

[ Textbox ]

Unknown

None

Please tell us about yourself or the person(s) on whose behalf you are making this complaint:

Title: Mr.Mrs.Ms.

First Name:

System will spell-check if user attempts to

enter “Anonymous”.

[ Textbox ]

Middle Name: [ Textbox ]

Last Name: [ Textbox ]

Street Address: [ Textbox ]

Address (Continued): [ Textbox ]

City: [ Textbox ]

State / Province: [ State / Province Dropdown List ]

Zip / Postal Code: [ Textbox ]

Country: [ Country Dropdown List ]

Telephone Number(s): [ Textbox ]

Email Address(es): [ Textbox ]

What is the best method to contact you?

Phone

Email

Mail Correspondence

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