Securities Complaint Form - Idaho

This printable "Securities Complaint Form" is a document issued by the Idaho Department of Finance specifically for Idaho residents.

Download a PDF of the latest edition of the form down below or find it through the department's forms library.

ADVERTISEMENT
IDAHO DEPARTMENT OF FINANCE
Securities Bureau
800 Park Blvd., Suite 200, Boise, ID 83712
P.O. Box 83720, Boise, ID 83720-0031
http://www.finance.idaho.gov
Fax: 208/332-8099
208/332-8004
Toll Free within Idaho: 1-888-346-3378
E-mail: securities@finance.idaho.gov
GUIDELINES FOR COMPLETING THE SECURITIES COMPLAINT FORM
Before filling out the attached complaint form, please take the time to read these guidelines; they will help you understand our
functions, and we will be better able to understand and act on your complaint.
WHAT WE CAN DO:
We investigate complaints against persons, business entities, and corporations accused of violating the licensing or anti-fraud
provisions of laws administered by the Department. We are empowered to bring administrative or civil actions to stop these
violations, and, in appropriate cases, to refer matters to the Prosecuting Attorneys' offices for criminal prosecution.
WHAT WE CANNOT DO:
We cannot act as a court of law, so we cannot order that monies be refunded, contracts be canceled or damages be awarded.
If you have this type of problem, you should consult an attorney.
We cannot give legal advice or act as your attorney.
HOW YOU CAN HELP US:
The purpose of this complaint form is to provide this Department with enough information to allow us to determine if an
investigation into your allegations is warranted. Thus, it is important for you to furnish as much detailed information as possible.
Documentary evidence is especially important, therefore, you should photocopy or scan all documents such as account
statements, contracts, agreements, certificates, notes, trust deeds, correspondence, legible copies of the front and back of
checks involved, escrow documents, advertising, etc., and attach them to the written complaint. (Please do not send originals;
we cannot be responsible for their safekeeping.)
How to submit complaint form and supporting documents:
You may complete all sections of this fillable form, save, print and sign. Then scan and email it along with your scanned
supporting documents to:
securities@finance.idaho.gov
or mail photocopied form and supporting documents to address below.
Or
You may print form, complete by hand (print clearly) and sign. Then mail along with your photocopied supporting documents to:
Idaho Department of Finance
Securities Bureau
P.O. Box 83720, Boise, ID 83720-0031
or
Express: 800 Park Blvd., Suite 200, Boise, ID 83712
If you have any questions concerning this form, you may contact the Securities Bureau at 208/332-8004.
IDAHO DEPARTMENT OF FINANCE
Securities Bureau
800 Park Blvd., Suite 200, Boise, ID 83712
P.O. Box 83720, Boise, ID 83720-0031
http://www.finance.idaho.gov
Fax: 208/332-8099
208/332-8004
Toll Free within Idaho: 1-888-346-3378
E-mail: securities@finance.idaho.gov
GUIDELINES FOR COMPLETING THE SECURITIES COMPLAINT FORM
Before filling out the attached complaint form, please take the time to read these guidelines; they will help you understand our
functions, and we will be better able to understand and act on your complaint.
WHAT WE CAN DO:
We investigate complaints against persons, business entities, and corporations accused of violating the licensing or anti-fraud
provisions of laws administered by the Department. We are empowered to bring administrative or civil actions to stop these
violations, and, in appropriate cases, to refer matters to the Prosecuting Attorneys' offices for criminal prosecution.
WHAT WE CANNOT DO:
We cannot act as a court of law, so we cannot order that monies be refunded, contracts be canceled or damages be awarded.
If you have this type of problem, you should consult an attorney.
We cannot give legal advice or act as your attorney.
HOW YOU CAN HELP US:
The purpose of this complaint form is to provide this Department with enough information to allow us to determine if an
investigation into your allegations is warranted. Thus, it is important for you to furnish as much detailed information as possible.
Documentary evidence is especially important, therefore, you should photocopy or scan all documents such as account
statements, contracts, agreements, certificates, notes, trust deeds, correspondence, legible copies of the front and back of
checks involved, escrow documents, advertising, etc., and attach them to the written complaint. (Please do not send originals;
we cannot be responsible for their safekeeping.)
How to submit complaint form and supporting documents:
You may complete all sections of this fillable form, save, print and sign. Then scan and email it along with your scanned
supporting documents to:
securities@finance.idaho.gov
or mail photocopied form and supporting documents to address below.
Or
You may print form, complete by hand (print clearly) and sign. Then mail along with your photocopied supporting documents to:
Idaho Department of Finance
Securities Bureau
P.O. Box 83720, Boise, ID 83720-0031
or
Express: 800 Park Blvd., Suite 200, Boise, ID 83712
If you have any questions concerning this form, you may contact the Securities Bureau at 208/332-8004.
COMPLAINT FORM
INFORMATION ABOUT YOU
A.
Last Name
First
Middle
Today's Date
Home Address
City
State
Zip
Telephone Number
Business Address
City
State
Zip
Telephone Number
Email Address
Trade or Occupation
Age
Marital Status
Are you willing to be interviewed by an investigator from this office?
Yes
No
Are you willing to be a witness if formal proceedings are commenced by the Idaho Department of Finance?
Yes
No
SUBJECT OF COMPLAINT
B.
Company Name
Address
Telephone No.
List persons who were involved in selling you the investment (please use separate pages to set forth any other
available information about these persons.)
Last Name
First
Middle
Position
Telephone No.
Address
City
State
Zip
Last Name
First
Middle
Position
Telephone No.
Address
City
State
Zip
2
Please explain your previous investment experience with either the company or the salesperson who contacted you.
Additionally, describe any personal relationships/dealings with the company or the salesperson.
C.
Questions About Your Investment:
Yes
No
N/A
If you used a broker, were investments in the account solicited, or recommended by the
broker?
Were trades made in your account without your authorization?
Did you receive a prospectus, private placement memorandum, private offering
memorandum, disclosure brochure, or any other disclosure document before making the
investment?
If a private investment opportunity, did you receive audited financial statements on the
company?
Did the person selling you the investment discuss the risks of the investment prior to
purchase?
Did you understand the risks of the investment?
Do you feel the investment was in line with your investment goals?
Did you have the financial ability to absorb the risk of the investment?
Did you understand where your money was to be invested?
If your investment was made from a brokerage account, did your account have a margin
agreement?
If you used a broker or investment adviser, did they have power of attorney or the authority to
enter transactions in your account?
3
INFORMATION ABOUT INVESTMENT
D.
What did you purchase or invest in? (Examples: common stock, debenture, limited partnership interest, investment
contract, fractional interests in an oil and gas lease). If available, include a copy of your most recent account
statement.
Date of Purchase
Security
No. of Shares
Unit Price
Total Price
Date of Purchase
Security
No. of Shares
Unit Price
Total Price
Date of Purchase
Security
No. of Shares
Unit Price
Total Price
How was the amount paid: (lump sum, installments, other / check, cash, wire, other)
Who received the payment from you?
Did you pay by mail?
To whom did you make your checks payable?
(Please provide a copy of both sides of the check if possible)
E.
Did you sign or receive any type of contract?
Yes
No
If yes, please enclose a copy.
Where was it signed (city/county)?
Were your securities delivered?
Where are your securities held?
If your securities have been delivered to you by mail, please attach a copy of the cover letter attached to your
securities.
F.
How did you learn of the investment? (Check more than one if applicable and enclose copies of pamphlets or
advertisements if available.)
Personal visit
Date
Location
Whom
Telephone call
Date
From whom
Where was the call received?
4
Advertising pamphlet/sales letter
Sent to you at what address/location
(If available, please include a copy of the pamphlet or letter)
Newspaper
Name of paper
(If available, include a copy of the newspaper advertisement.)
Date
Radio
Name of station
Date
Television
Name of station
Date
Group Sales Presentation
Date of presentation
Where was presentation held?
Other (Please Specify)
G.
List others who were present when the offers or sales were made to you.
Name
Address
Telephone
Relationship to Complainant
Name
Address
Telephone
Relationship to Complainant
Name
Address
Telephone
Relationship to Complainant
H.
Who else do you know that invested with the company, corporation, or association?
Name
Address
Telephone
Relationship to Complainant
Name
Address
Telephone
Relationship to Complainant
Name
Address
Telephone
Relationship to Complainant
5

Download Securities Complaint Form - Idaho

1182 times
Rate
4.5(4.5 / 5) 71 votes
ADVERTISEMENT
Page of 7