Complaint Form - Alabama Securities Commission

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ALABAMA SECURITIES COMMISSION
COMPLAINT FORM
STATE NAME AND ADDRESS OF FIRM OR PERSON COMPLAINT IS AGAINST:
Name: _________________________________________________________________________________
Address: _______________________________________________________________________________
City: ______________________ State: ________ Zip Code: _______________
Phone Number: ________________
Email: _____________________________________________
STATE YOUR NAME AND ADDRESS:
Name: _________________________________________________________________________________
Address: _______________________________________________________________________________
City: ______________________ State: ________ Zip Code: _______________
Home Phone Number: ____________________ Work Phone Number: ______________________
Email: ________________________________________________________________________________
TYPE OF COMPLAINT:
Complaint against a Company or Firm
Complaint against an Individual
Other, Please Specify:_____________________________________________________________
_____________________________________________________________
Date of Transaction: _________________
Place of Transaction (Specify the States in which you and the salesman were located) _______________
_______________________________________________________________________________________
Witnesses to the Transaction:______________________________________________________________
_______________________________________________________________________________________
State the type of investment involved (e.g. stock, note, limited partnership, etc. If you are not certain,
describe on last page.) ____________________________________________________________________
_______________________________________________________________________________________
• If you invested in stock or bonds, what was the name of the issuing corporation?
_________________________________________________________________________________
• If you invested in a note, who was the maker (Company or Individual) responsible for paying it?
_________________________________________________________________________________
• If you invested in a partnership, what was the name of that partnership?
_________________________________________________________________________________
• Other: __________________________________________________________________________
_________________________________________________________________________________
Amount involved in transaction: _________________________________
Do you have and can you provide evidence of investment (front and back of checks; cashiers checks;
money orders; etc.)?
NO
YES
Did you sign any papers or documents? NO
YES
(If Yes, please attach copies of them.)

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