"Investor Complaint Form" - Mississippi

Investor Complaint Form is a legal document that was released by the Mississippi Secretary of State - a government authority operating within Mississippi.

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INVESTOR COMPLAINT FORM
DIRECTIONS:
The information you provide on this form is important to enable the Division to investigate your
complaint. Note that this Division cannot guarantee monetary recovery on your behalf. Please
furnish specific and detailed information, answer all questions which are applicable to your situation, and
be clear and complete in your answers. Failure to provide all relevant information may delay the
processing of your complaint.
=====================================================================
I.
INVESTOR INFORMATION
Full Name ___________________________________________ Date ___________________
Address _____________________________________________ County _________________
City/State/Zip ________________________________________ Work Phone _____________
Occupation ___________________________________________ Home Phone _____________
Cell Phone_____________________________
Email ____________________________________
II.
FACTS AND CIRCUMSTANCES
1. Against whom are you filing this complaint? Please provide name, address, and telephone.
____________________________________________________________________________________
____________________________________________________________________________________
2. Date and means of initial contact (E.g., newspaper ad, mail, telephone solicitation, referral, etc.). Who
made the initial contact?
____________________________________________________________________________________
____________________________________________________________________________________
1
INVESTOR COMPLAINT FORM
DIRECTIONS:
The information you provide on this form is important to enable the Division to investigate your
complaint. Note that this Division cannot guarantee monetary recovery on your behalf. Please
furnish specific and detailed information, answer all questions which are applicable to your situation, and
be clear and complete in your answers. Failure to provide all relevant information may delay the
processing of your complaint.
=====================================================================
I.
INVESTOR INFORMATION
Full Name ___________________________________________ Date ___________________
Address _____________________________________________ County _________________
City/State/Zip ________________________________________ Work Phone _____________
Occupation ___________________________________________ Home Phone _____________
Cell Phone_____________________________
Email ____________________________________
II.
FACTS AND CIRCUMSTANCES
1. Against whom are you filing this complaint? Please provide name, address, and telephone.
____________________________________________________________________________________
____________________________________________________________________________________
2. Date and means of initial contact (E.g., newspaper ad, mail, telephone solicitation, referral, etc.). Who
made the initial contact?
____________________________________________________________________________________
____________________________________________________________________________________
1
3. State the full name of the person who sold the investment to you.
___________________________________________________________________________________
___________________________________________________________________________________
4. Other names associated with the person who sold the investment to you, such as a brokerage firm,
company, or other principals or associates, etc. Please provide names, addresses and telephone numbers.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
5. The following information relates to the actual investment you made. Please provide complete factual
data.
a. Name of Investment ________________________________________________________________
b. Type of Investment (E.g., stocks, bonds, limited partnership interests, joint venture, etc.)
___________________________________________________________________________________
c. Date of Investment _________________________________________________________________
d. Number of Shares or Interests Purchased ________________________________________________
e. Price per Share/Total Purchase Price ___________________________________________________
f. Where did this transaction take place? Who was present?
___________________________________________________________________________________
___________________________________________________________________________________
g. How did you pay for this investment (E.g., cash, check, money order, wire transfer, etc.)?
___________________________________________________________________________________
6. What were you told that made you decide to invest, such as, the type of profits you might receive, how
risky or safe the investment would be, information about the future value of your investment, etc.? Who
told you this?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
2
7. What were you told about how the company was going to use your funds?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
8. Did you make the company/salesperson aware of your financial situation, investment objectives, and/or
your risk tolerance? If so, what was said, to whom, and when?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
9. How frequently were you in contact with the company/your salesperson? With whom were you in
contact and what did you discuss?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
10. Were you encouraged to invest more money in the same or similar investment? If so, what was said to
you, by whom, and when?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
11. Specifically, describe your complaint:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
12. Have you calculated or evaluated your losses? ________
If so, did you have someone assist you with the evaluation, such as an attorney or CPA? ____________
If not, how did you evaluate any losses, and what was the result of this evaluation?
_____________________________________________________________________________
_____________________________________________________________________________
3
13. How would you like your complaint to be resolved? Please be specific.
____________________________________________________________________________________
____________________________________________________________________________________
14. Describe any contacts you have had with the company/your salesperson concerning your complaint.
Please forward copies of any correspondence and other documents between you and the company/your
salesperson.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
15. Have you filed a complaint with any other agency regarding this matter? If so, please furnish the
name of the agency, when filed, and status if known.
___________________________________________________________________________________
___________________________________________________________________________________
16. Have you contacted a private attorney about this matter? If so, please include the attorney's name,
address, and telephone.
___________________________________________________________________________________
___________________________________________________________________________________
17. If you are aware of anyone else who has made a similar investment, please provide names and
addresses.
___________________________________________________________________________________
___________________________________________________________________________________
18. Have you ever invested in this type of product or investment before? If so, please describe your past
experiences.
___________________________________________________________________________________
___________________________________________________________________________________
19. Please include any additional relevant information not previously mentioned.
___________________________________________________________________________________
___________________________________________________________________________________
4
III.
OTHER INFORMATION
Documentary evidence is especially important. Please forward copies, not originals, of the front and back
of your canceled checks, confirmations, statements, correspondence, certificates, prospectuses, and any
other written materials pertaining to your complaint. If you need more space, please feel free to attach
additional pages.
Mail your documents and completed complaint form to:
Securities Division
Secretary of State’s Office
P.O. Box 136
Jackson, MS 39205-0136
IV.
NOTICE
Your complaint will remain confidential pursuant to Mississippi Securities Act § 75-71-607. It is
unlawful for any person to make or cause to be made, in any document filed with the Secretary of State or
in any proceeding, any statement which is, at the time and in the light of the circumstances under which it
is made, false or misleading in any material respect. Miss. Code Ann. § 75-71-505 (2009).
_______________________________________
Signature
_______________________________________
Date
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