"Complaint Form" - Arkansas

Complaint Form is a legal document that was released by the Arkansas Securities Department - a government authority operating within Arkansas.

Form Details:

  • The latest edition currently provided by the Arkansas Securities Department;
  • Ready to use and print;
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Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Arkansas Securities Department.

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Download "Complaint Form" - Arkansas

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Rate (4.3 / 5) 17 votes
 
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 300 
SA
UTCHINSON
ERITAGE
EST
UILDING
UITE
          G
 
201 E
 M
 S
 
OVERNOR
AST
ARKHAM
TREET
 
L
 R
, A
 72201­1692 
ITTLE
OCK
RKANSAS
    B. E
 W
 
T
: (501) 324­9260 
DMOND
ATERS
ELEPHONE
       C
 
F
: (501) 324­9268 
OMMISSIONER
ACSIMILE
                                                                         
  
A
 S
 D
 
RKANSAS
ECURITIES
EPARTMENT
 
     COMPLAINT FORM 
 
 
INSTRUCTIONS:
Upon receipt of a properly completed “Complaint Form”, the Arkansas
 
 
   
 
 
 
 
 
 
Securities Department (ASD) will review the complaint and, generally request
 
 
 
 
 
 
 
 
 
 
a response from the company or individual that is the subject of the complaint.
 
 
 
 
   
 
   
 
   
 
 
Based on this information, ASD will decide whether or not to begin a formal
 
 
 
 
 
 
 
   
   
   
 
investigation.
 
If a formal investigation begins, it will ordinarily remain
   
 
 
   
 
 
 
confidential, as will any related documentation. You are invited to attach
 
 
 
 
 
 
 
 
   
 
photocopies (no originals please) of supporting documents to the Complaint
 
 
 
   
 
   
 
 
Form. 
 
Please Check One: 
Securities 
Broker­dealer 
Investment 
 
 
 
Adviser 
 
 
Mortgage Company 
Loan Officer 
 
 
 
 
 
 
Money Transmitter 
Currency Exchange 
 
 
 
 
 
Please provide the following information about yourself: 
 
 
 
Last name 
First name 
Middle initial 
 
 
 
 
 
Street Address 
City 
State 
Zip 
 
 
 
 
 
Daytime phone 
Evening phone 
Best time to call 
E­mail address 
 
Please provide the following information for the company your complaint is against: 
 
 
Company name 
Street Address 
 
 
 
 
 
City 
State 
Zip 
Phone number 
 
Person you dealt with at the company: 
 
 
 
Last name 
First name 
Middle initial 
 
 
      A
 H
 
H
 W
 B
, S
 300 
SA
UTCHINSON
ERITAGE
EST
UILDING
UITE
          G
 
201 E
 M
 S
 
OVERNOR
AST
ARKHAM
TREET
 
L
 R
, A
 72201­1692 
ITTLE
OCK
RKANSAS
    B. E
 W
 
T
: (501) 324­9260 
DMOND
ATERS
ELEPHONE
       C
 
F
: (501) 324­9268 
OMMISSIONER
ACSIMILE
                                                                         
  
A
 S
 D
 
RKANSAS
ECURITIES
EPARTMENT
 
     COMPLAINT FORM 
 
 
INSTRUCTIONS:
Upon receipt of a properly completed “Complaint Form”, the Arkansas
 
 
   
 
 
 
 
 
 
Securities Department (ASD) will review the complaint and, generally request
 
 
 
 
 
 
 
 
 
 
a response from the company or individual that is the subject of the complaint.
 
 
 
 
   
 
   
 
   
 
 
Based on this information, ASD will decide whether or not to begin a formal
 
 
 
 
 
 
 
   
   
   
 
investigation.
 
If a formal investigation begins, it will ordinarily remain
   
 
 
   
 
 
 
confidential, as will any related documentation. You are invited to attach
 
 
 
 
 
 
 
 
   
 
photocopies (no originals please) of supporting documents to the Complaint
 
 
 
   
 
   
 
 
Form. 
 
Please Check One: 
Securities 
Broker­dealer 
Investment 
 
 
 
Adviser 
 
 
Mortgage Company 
Loan Officer 
 
 
 
 
 
 
Money Transmitter 
Currency Exchange 
 
 
 
 
 
Please provide the following information about yourself: 
 
 
 
Last name 
First name 
Middle initial 
 
 
 
 
 
Street Address 
City 
State 
Zip 
 
 
 
 
 
Daytime phone 
Evening phone 
Best time to call 
E­mail address 
 
Please provide the following information for the company your complaint is against: 
 
 
Company name 
Street Address 
 
 
 
 
 
City 
State 
Zip 
Phone number 
 
Person you dealt with at the company: 
 
 
 
Last name 
First name 
Middle initial 
 
 
      A
 H
 
H
 W
 B
, S
 300 
SA
UTCHINSON
ERITAGE
EST
UILDING
UITE
          G
 
201 E
 M
 S
 
OVERNOR
AST
ARKHAM
TREET
 
L
 R
, A
 72201­1692 
ITTLE
OCK
RKANSAS
    B. E
 W
 
T
: (501) 324­9260 
DMOND
ATERS
ELEPHONE
       C
 
F
: (501) 324­9268 
OMMISSIONER
ACSIMILE
                                                                         
  
A
 S
 D
 
RKANSAS
ECURITIES
EPARTMENT
 
Please briefly describe your complaint below (attach additional pages if necessary): 
 
 
 
 
 
 
 
 
Please provide information regarding legal representation/action: 
 
 
Is an attorney representing you in this matter? 
Yes 
No 
 
 
 
 
 
 
 
If you have an attorney for this matter, may we 
Yes 
No 
Not Applicable 
 
 
 
contact your attorney? 
 
 
 
 
 
 
Attorney last name 
First name 
Law firm name 
 
 
 
 
City 
State 
Zip 
Phone number 
 
 
PLEASE READ BEFORE SIGNING:
 
By signing this Complaint Form I acknowledge that
 
 
 
 
   
 
 
(1) the information I have provided is true to the best of my knowledge and belief, (2) I have read and
 
 
   
 
   
   
 
   
 
 
 
 
   
 
 
 
understand the Notice in the paragraph below, and (3) I authorize the ASD to provide information from
 
 
   
 
 
 
 
   
 
 
   
 
 
 
this Complaint Form to the company that is the subject of the complaint, or to use the information I
 
 
   
 
 
   
 
   
 
     
 
 
   
have provided in any manner deemed necessary or proper by the ASD. 
 
NOTICE:
 
​ T he ASD does not provide personal legal advice, nor will it represent you in court
 
 
 
 
 
 
 
 
 
   
 
   
 
proceedings. Also ASD cannot decide disputes, arbitrate claims or order firms to pay judgments in
 
 
 
 
 
 
 
   
 
   
 
   
personal disputes. In order to recover lost funds or obtain comparable relief, you may have to initiate
 
 
 
   
 
 
   
 
 
 
 
 
   
 
private legal action; prompt action on your part is critical because state and federal laws known as
 
 
 
 
 
 
 
   
 
 
 
 
 
 
   
“Statutes of Limitations” impose strict time limits on filing law suits. Thus, you may wish to contact
   
 
 
 
 
   
 
 
 
 
 
 
   
 
an attorney immediately. For names of attorneys in your area, call the Arkansas Bar Association or
 
 
 
 
   
   
 
 
 
 
 
 
   
your local bar​   ​ a ssociation. 
 
 
      A
 H
 
H
 W
 B
, S
 300 
SA
UTCHINSON
ERITAGE
EST
UILDING
UITE
          G
 
201 E
 M
 S
 
OVERNOR
AST
ARKHAM
TREET
 
L
 R
, A
 72201­1692 
ITTLE
OCK
RKANSAS
    B. E
 W
 
T
: (501) 324­9260 
DMOND
ATERS
ELEPHONE
       C
 
F
: (501) 324­9268 
OMMISSIONER
ACSIMILE
                                                                         
  
A
 S
 D
 
RKANSAS
ECURITIES
EPARTMENT
 
 
Date 
Signature:   
 
 
Signed:: 
 
Checking this box constitutes your legal signature and acceptance of the above agreement.
 
 
 
 
 
 
Please return the completed form to ASD by e­mailing ​
 
 
 
 
   
 
 
 
i nfo@securities.arkansas.gov
 
or by mailing to the
 
 
   
 
address above.  The form MUST be signed either by hand or by checking the signature box. 
 
 
 
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