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
September 30, 2014

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://tts2.sec.gov/oiea/Complaint.html



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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://tts2.sec.gov/oiea/Complaint.html

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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

This collection of information has been reviewed by the Office of Management
and Budget ("OMB") in accordance with the clearance requirements of 44 U.S.C.
§3507. The applicable Privacy Act system of records (SORN) is SEC 65 and the
routine uses of the records are set forth at 76 FR 30213 (May 24, 2011). This
SORN is exempt from certain sections of the Privacy Act and the citation for the
rule exempting the notice is 76 FR 57636 (September 16, 2011).
https://tts.sec.gov/oiea/Complaint.html
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9/15/2014