Complaint Report Form - Washington State Department Of Financial Institutions
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4Securities Division
PO Box 9033
Olympia WA 98507-9033
360-902-8760
Fax: 360-902-0524
Complaint Report
Please print or type:
Investor Information
Your Name ______________________________________________ Birth Date ______________
Address _______________________________________________________________________
City _____________________________ State _______________ Zip Code _________________
Phone (day) _____________________ (eve) ___________________ Best time to call _________
E-mail Address ____________________________________ Occupation ___________________
Complaint Against
Name of business _______________________________________________________________
Person you dealt with _____________________________________________________________
Address _______________________________________________________________________
City _____________________________ State ________________ Zip Code ________________
Phone ________________________ Cell phone (if any) ______________________
Business E-mail or Web Site Address ________________________________________________
Names, Addresses, and phone numbers of any other businesses, or persons involved in your
complaint:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Revised 10/31/02
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