Investor Form

SEC Investor Complaint Form

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Investor Complaint Form
You may use this form to send your complaint to the SEC. Although we use
secure socket layer encryption, do not hesitate to print this form and send it by
mail or fax if you have any concerns about security. Please read our Privacy Act
Notice to learn more about how we may use the information you send to us.

OMB Number:
Expires:

3235-0547
November 30, 2011

Estimated average burden
hours per response: 0.25

Please read our brochure, How We Handle Complaints, for information on what
we will do with your complaint, your legal rights, and options for resolving your
complaint.







Yes, send the form
to the firm or
company.







No, do not send the form to the firm or
company. If you choose "no", we will record
your complaint in our database, but we cannot
help you any further.

Tell Us About Yourself
* You must complete this information.
Title



* First name
Middle initial
* Last name
* Street address
Address (cont.)
* City
* State/Province



(required if US or
Canada)

* Zip/Postal code
* Country



UNITED STATES

Daytime phone
Alternate phone
Fax
* E-mail
* Are you a



Tell Us About the Firm or Individual You Have a Complaint Against
Firm name
Type of firm



Broker, Advisor, or
Salesperson
Street address
Address (cont.)
City
State/Province

https://tts.sec.gov/oiea/Complaint.html



6/8/2011

SEC Investor Complaint Form

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Zip/Postal code
Country



Tell Us About Your Investment
Type of
security



Security
symbol
Name of
Issuer or
Security

Tell Us About Your Complaint
* Please describe your complaint in as much detail as possible, including the full
name(s) on the account, the exact type of account, the dates of specific
transactions or conversations, the name or ticker symbol of the security(ies)
involved, and the names of all the people at the firm you have contacted about
this complaint.




What types of documents would you be able to provide us if requested?
 Canceled Checks





 Correspondence to and from Firm




 Advertising or Marketing Materials





 Notes of conversation with Firm




 Other





Tell Us What Action You Have Taken
Have you complained to the firm?
 Yes 




 No




https://tts.sec.gov/oiea/Complaint.html

6/8/2011

SEC Investor Complaint Form

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Have you contacted any other regulators?
 Yes 




 No



If yes, whom?
 FINRA (Financial Industry Regulatory Authority)





 State Regulators




 Other Federal Regulators





 Foreign Regulators




 Stock Exchange







 Other





Have you taken legal action?

If so, what type:

 Mediation





 Arbitration




 Court Action





Describe the details of the legal action you have taken.




Submit Form

Clear Form

https://tts.sec.gov/oiea/Complaint.html
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https://tts.sec.gov/oiea/Complaint.html

6/8/2011