Tips, Complaints and Referral Database-Pilot Phase

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
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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)

2

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)

3

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 / MarkUps / 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])

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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?

5

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

6

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

7

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

8

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]

9

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

10

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:

11

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

12