Public Complaint Form - Georgia Secretary Of State
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1SECURITIES AND BUSINESS REGULATION
2 Martin Luther King, Jr. Drive, S.E.
Ste 802, West Tower
Atlanta, Georgia 30334
(404) 656-3920
ROBERT D. TERRY
DIVISION DIRECTOR
KAREN HANDEL
PUBLIC COMPLAINT FORM
Secretary of State
Your Information
Your Name:
Address:
Telephone: (
)
Your Signature:
Date:
Please Mark Area(s) of Complaint
Securities
Cemeteries/Preneed Funeral Home/ Preneed Dealer
Securities Broker/Dealer
Cemeteries Merchandise Dealer
Securities Salesperson
Cemeteries Preneed Sales Agent
Securities Investment Advisor
Charitable Organization
Securities Investment Advisor Representative
Charities Paid Solicitor
Charities Solicitor Agent
Information Relating to Business or Individual Involved
Name
Registration Number
Telephone
Address
Address
City
State
Zip Code
Names of other businesses or individuals involved (explain below):
Information Relating to Complaint
Date the business or individual contacted you?
How were you contacted (phone, mail, in person, etc.)?
Date of investment/purchase/donation?
What did you invest in, purchase, or donate (explain)?
Did you sign any documents (if so, please explain)?
List all pertinent witnesses and their phone numbers?
Have you brought any legal action (if so, what)?
Please attach a detailed explanation of your complaint. Include names, addresses, dates, amount, etc. Send copies of all
relevant materials pertaining to your complaint to the address above,
ATTN: Complaint Coordinator
This Complaint Form may be sent to a professional trade organization or other similar organization related to the business identified in
the complaint in an effort to resolve this dispute. If for any reason you do not want a copy of this complaint sent to such an
organization, please put an 'X' HERE:
_____ I do not want this complaint sent to a professional trade organization.
Public Complaint Form Rev. 8/2006
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Parent category: Legal