Complaint Form - Alabama Securities Commission printable pdf download

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.)?

YES

Did you sign any papers or documents? NO

YES

(If Yes, please attach copies of them.)

Complaint Form - Alabama Securities Commission