Department Complaint Form - Rhode Island Department Of Business Regulation printable pdf download

STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS

DEPARTMENT OF BUSINESS REGULATION

DIVISION OF SECURITIES

233 RICHMOND STREET - SUITE 232

PROVIDENCE, RI 02903-4232

DEPARTMENT COMPLAINT FORM

Office Use Only

Case No. ________________

Date Filed _____________

INSTRUCTIONS: Please complete this form and return to above address if you have reason to believe that a licensee regulated by the

department has violated the law or failed to meet their responsibilities and obligations to the public.

Complainant's Name: Last ________________________________ First_______________________________ Middle_____________

Residence Street___________________________________ City/Town________________________ State_____ Zip______________

Mailing Address (if different from residence)__________________________________________________________________________

Home Telephone________________________________ Business Telephone & Extension____________________________________

Name, Address, Phone of person who always knows where to contact me __________________________________________________

Licensee or regulated activity about whom or which I am making complaint _______________________________________________

Address (Business or Residence) ____________________________________________________ Phone_______________________

Type of Licensee or Regulated Activity

Securities

Charitable Organizations

___Time Shares

Broker Dealer

Fund Raiser

Franchisor

___Investment Adviser

Date, Time and Place of alleged violation__________________________________________________________________________

____________________________________________________________________________________________________________

Other Federal, State, Municipal, local agencies or legal counsel I have contacted with regard to this complaint, including results of contacts.

Explain as fully as possible on the reverse side the exact nature of your complaint against the licensee or regulated activity. Be sure to

attach copies of any documentation which will help support your allegations including, but not limited to statements, contracts, purchase

agreements, cancelled checks, circulars, prospectuses, advertising, etc.

(SEE OTHER SIDE)

The undersigned swears to or affirms the truth and accuracy of all statements, answers, representations and allegations contained herein,

including all statements hereto attached.

SIGNED

DATE_________________

A COPY OF THIS COMPLAINT WILL BE FORWARDED TO THE LICENSEE ABOUT WHICH YOU HAVE COMPLAINED.

(SEE OTHER SIDE)

Department Complaint Form - Rhode Island Department Of Business Regulation