"Consumer Complaint Form" - Washington

Consumer Complaint Form is a legal document that was released by the Washington State Department of Financial Institutions - a government authority operating within Washington.

Form Details:

  • Released on March 21, 2006;
  • The latest edition currently provided by the Washington State Department of Financial Institutions;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Washington State Department of Financial Institutions.

ADVERTISEMENT
ADVERTISEMENT

Download "Consumer Complaint Form" - Washington

Download PDF

Fill PDF online

Rate (4.8 / 5) 6 votes
Page background image
State of Washington
DEPARTMENT OF FINANCIAL INSTITUTIONS
DIVISION OF SECURITIES
P.O. Box 41200
Olympia, Washington 98504-1200
FAX (360) 902-0524
Telephone (360) 902-8700
TDD (360) 664-8126
http://www.dfi.wa.gov
Consumer Complaint
We have found complaints can normally be resolved if the consumer contacts the company
directly. If you have not already done so, please contact the company and attempt to resolve
the problem. If direct contact is unsuccessful or you are not satisfied with the results, please fill
out this form and send it, along with copies of the company’s response and any other
appropriate documentation, to the Division of Securities. Your complaint will be promptly
acknowledged, and you will be notified of the final disposition.
Public Records Disclosure Act:
The Washington Public Records Act (PRA), RCW 42.56, may require disclosure of a
complaint after a file is closed. If you choose, you may keep your identifying information
exempt from disclosure under the PRA by checking this box. Please note that this exemption
does not necessarily restrict the release of your identifying information pursuant to a court
order, subpoena, or during litigation.
Your Information:
Name: ____________________________________________________________________
Mailing Address: ___________________________________________________________
City: __________________________
State: _____
Zip: ________________________
Telephone: (_____) _______ - _________
Fax Number: (_____) _______ - ________
Email Address: _____________________________________________________________
Your Complaint is Against the Following Business:
Business Name: ____________________________________________________________
Address: __________________________________________________________________
City: __________________________
State: _____
Zip: _________________________
Telephone: (_____) _______ - _________
Fax Number: (_____) _______ - _________
Who You Contacted: _________________________________________________________
Page 1 of 4
State of Washington
DEPARTMENT OF FINANCIAL INSTITUTIONS
DIVISION OF SECURITIES
P.O. Box 41200
Olympia, Washington 98504-1200
FAX (360) 902-0524
Telephone (360) 902-8700
TDD (360) 664-8126
http://www.dfi.wa.gov
Consumer Complaint
We have found complaints can normally be resolved if the consumer contacts the company
directly. If you have not already done so, please contact the company and attempt to resolve
the problem. If direct contact is unsuccessful or you are not satisfied with the results, please fill
out this form and send it, along with copies of the company’s response and any other
appropriate documentation, to the Division of Securities. Your complaint will be promptly
acknowledged, and you will be notified of the final disposition.
Public Records Disclosure Act:
The Washington Public Records Act (PRA), RCW 42.56, may require disclosure of a
complaint after a file is closed. If you choose, you may keep your identifying information
exempt from disclosure under the PRA by checking this box. Please note that this exemption
does not necessarily restrict the release of your identifying information pursuant to a court
order, subpoena, or during litigation.
Your Information:
Name: ____________________________________________________________________
Mailing Address: ___________________________________________________________
City: __________________________
State: _____
Zip: ________________________
Telephone: (_____) _______ - _________
Fax Number: (_____) _______ - ________
Email Address: _____________________________________________________________
Your Complaint is Against the Following Business:
Business Name: ____________________________________________________________
Address: __________________________________________________________________
City: __________________________
State: _____
Zip: _________________________
Telephone: (_____) _______ - _________
Fax Number: (_____) _______ - _________
Who You Contacted: _________________________________________________________
Page 1 of 4
Additional Information:
Names, addresses, phone numbers of any other businesses, or persons involved in your
complaint.
How and when did you first hear about this investment?
How much money did you invest?
What Dates?
What kind of investment(s) did you buy?
How did you pay for your investment(s)?
(e.g. personal or cashier’s check, cash, wire transfer, etc.)
What method did you use to deliver the payment?
(e.g. in person, mail, fed ex, etc.)
How and when did the person first contact you?
Please list any courier or postal service used by the person to contact you and when that contact
occurred.
Have you complained to the person or firm? If yes, please describe. Was your complaint in writing,
or did you speak to someone? If in writing, please send a copy of the complaint. If you spoke with
a person, who was it and when did it happen?
Have you contacted any other regulator or taken any legal action? If yes, please describe.
Page 2 of 4
Explain Your Complaint in Detail:
Please provide a detailed explanation of the facts that led to your complaint. Start at the beginning
and continue through to the present. Be sure to include AT LEAST the following information: How,
when, and from whom did you first hear about this investment? What verbal and/or written
information did you receive about the investment? Did you later find that any of this information
was untrue?
Page 3 of 4
Other Investors:
Do you know anyone else who purchased the investment that is the subject of this complaint?
If so, please list their names, addresses, and phone numbers.
Jurisdiction of the Securities Division:
The jurisdiction of the Securities Division generally extends only to issues connected with the
initial offer and sale of securities, franchises, business opportunities, and commodities. We may
not have jurisdiction if your complaint involves later actions by management that you think are
unfair to investors, or in actions by management such as the failure to hold shareholder meetings
or provide annual reports. However, you may have civil remedies available to address your
complaint, so please consult your attorney. Also, the Division does not have the authority to
represent you in civil litigation, which means you must hire your own attorney to recover your
investment funds.
Declaration:
By signing my name below, I declare, under penalty of perjury under the laws of the State of
Washington that the information contained in this complaint is true and accurate and the
information may be used to further investigate the complaint.
____________________________
______________________________________
Date
Signature
Revised: 03/21/2006
Page 4 of 4
Page of 4