"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;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable 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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1 COMMERCE WAY, SUITE 402
A
H
SA
UTCHINSON
RKANSAS 72202
L
R
, A
ITTLE
OCK
G
OVERNOR
T
: (501) 324-9260
ELEPHONE
F
: (501) 324-9268
ERIC MUNSON
ACSIMILE
C
OMMISSIONER
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
Broker-dealer
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
E-mail 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
1
1 COMMERCE WAY, SUITE 402
A
H
SA
UTCHINSON
RKANSAS 72202
L
R
, A
ITTLE
OCK
G
OVERNOR
T
: (501) 324-9260
ELEPHONE
F
: (501) 324-9268
ERIC MUNSON
ACSIMILE
C
OMMISSIONER
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
Broker-dealer
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
E-mail 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
1
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:
The 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 association.
Signature:
Date Signed::
Checking this box constitutes your legal signature and acceptance of the above agreement.
ASDInfo@Arkansas.gov
Please return the completed form to ASD by e-mailing
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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