"Investor Protection Unit Complaint Form" - Delaware

Investor Protection Unit Complaint Form is a legal document that was released by the Delaware Department of Justice - a government authority operating within Delaware.

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Download "Investor Protection Unit Complaint Form" - Delaware

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COMPLAINT FORM
INVESTOR PROTECTION UNIT
RETURN THIS FORM TO:
FOR OFFICIAL USE:
INVESTOR PROTECTION UNIT
DELAWARE DEPARTMENT OF JUSTICE
Case Number:____________
TH
820 N. FRENCH STREET, 5
FLOOR
Investigator:_____________
WILMINGTON, DE 19801
Phone: (302) 577-8424
Fax: (302) 577-6987
Email:
investor.protection@state.de.us
Your Name:
Name of Person or Business Complaint is Against:
__________________________________________
___________________________________________
Your Home Address:
Their Address:
__________________________________________
___________________________________________
Number and Street
Number and Street
__________________________________________
___________________________________________
City
City
__________________________________________
__________________________________________
State and Zip Code
State and Zip Code
Phone Numbers:
Phone Number(s): __________________________
Home: ____________________________________
Email: ____________________________________
Work: ____________________________________
Other Affiliated Persons/Entities:______________
Email: ____________________________________
__________________________________________
CRD Number, if known: _____________________
If you are not a resident of Delaware, please specify why you are filing your complaint with the State of
Delaware (NOTE: incorporating a company in Delaware is rarely enough grounds to pursue a case):
_____________________________________________________________________________________
_____________________________________________________________________________________
INVESTOR PROTECTION UNIT
COMPLAINT FORM, Page 1
COMPLAINT FORM
INVESTOR PROTECTION UNIT
RETURN THIS FORM TO:
FOR OFFICIAL USE:
INVESTOR PROTECTION UNIT
DELAWARE DEPARTMENT OF JUSTICE
Case Number:____________
TH
820 N. FRENCH STREET, 5
FLOOR
Investigator:_____________
WILMINGTON, DE 19801
Phone: (302) 577-8424
Fax: (302) 577-6987
Email:
investor.protection@state.de.us
Your Name:
Name of Person or Business Complaint is Against:
__________________________________________
___________________________________________
Your Home Address:
Their Address:
__________________________________________
___________________________________________
Number and Street
Number and Street
__________________________________________
___________________________________________
City
City
__________________________________________
__________________________________________
State and Zip Code
State and Zip Code
Phone Numbers:
Phone Number(s): __________________________
Home: ____________________________________
Email: ____________________________________
Work: ____________________________________
Other Affiliated Persons/Entities:______________
Email: ____________________________________
__________________________________________
CRD Number, if known: _____________________
If you are not a resident of Delaware, please specify why you are filing your complaint with the State of
Delaware (NOTE: incorporating a company in Delaware is rarely enough grounds to pursue a case):
_____________________________________________________________________________________
_____________________________________________________________________________________
INVESTOR PROTECTION UNIT
COMPLAINT FORM, Page 1
INVESTMENT INFORMATION
When did the investment transaction(s) you are complaining of take place:
Place of transaction(s). Please specify the state(s) in which you and the salesman were located when
the transaction(s) took place.
Identify any witnesses to the transaction: ___________________________________________________
How much money did you invest: ________________________________________________________
What was the source of your investment funds (savings, retirement account, loan, etc)? _____________
Do you have and can you provide evidence of investment (front and back of checks; cashier’s checks;
money orders; bank statements; account statements; etc.)?
YES
NO
Please give a brief explanation of your prior investment experience.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please give a brief explanation of how you learned about this investment.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What were you told your money would be used for?
_____________________________________________________________________________________
_____________________________________________________________________________________
Were you promised a specific return on your investment?
_____________________________________________________________________________________
What were you told about the risks of this investment?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Did you receive a offering document, prospectus, or other information describing the investment?
_____________________________________________________________________________________
Did the seller give you information that later turned out to be untrue? If yes, please explain:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Did you sign any papers or documents in connection with the investment(s)?
YES
NO
If Yes, please attach copies of them.
INVESTOR PROTECTION UNIT
COMPLAINT FORM, Page 2
Have you complained to the Company or Firm?
YES
NO
If yes, to whom?
_____________________________________________________________________________________
What was the response?
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you made a complaint with any other governmental or regulatory agencies?
YES
NO
If yes, who? __________________________
Which agency? _________________________________
At what address? ______________________________________________________________________
Please provide the names, telephone numbers, and addresses of other known investors.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Does an attorney represent you in this matter? YES
NO
If yes, provide attorney's name and address:
_____________________________________________________________________________________
_____________________________________________________________________________________
Have you or other victims filed a lawsuit against anyone regarding this investment? YES
NO
If yes, provide name of court: ____________________________________________________________
Case number: _____________________________ Date case filed: ______________________________
Attach copies of court documents to this complaint.
NARRATIVE
Please PRINT or TYPE your complaint in FULL detail. You may add additional sheets if necessary.
INVESTOR PROTECTION UNIT
COMPLAINT FORM, Page 3
Narrative continued, if necessary:
Attach COPIES, not originals, of all related documents, including advertisements, contracts,
receipts, bills, cancelled checks, written agreements, letters or emails.
READ THE FOLLOWING CAREFULLY BEFORE SIGNING BELOW:
• I have attached copies of all papers that relate to this complaint.
• I understand that in order to successfully handle this complaint, the Investor
Protection Unit may need to send this complaint to the person or firm that I have
complained about.
YOU MUST CHECK ONE OF THE FOLLOWING:
____ You have my permission to send this complaint to the person or business I have
complained.
____ You DO NOT have my permission to send this complaint to the person or business I
have complained.
The information contained in this complaint is true to the best of my knowledge.
_______________________________________
____________________
Signature
Date
Please be advised:
• The Delaware Department of Justice is prohibited by law from giving you legal advice,
legal opinions, or acting as your private attorney.
• You may have a private right of action that must be acted upon within certain time
limits; filing this complaint with the Delaware Department of Justice will not stop
those time limits from running.
Therefore, you should consult with a private attorney to discuss your legal rights and
remedies.
INVESTOR PROTECTION UNIT
COMPLAINT FORM, Page 4
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