Complaint Form - Commonwealth Of Pennsylvania Pennsylvania Securities Commission (Page 2 of 4) in pdf

Complaint Form - Commonwealth Of Pennsylvania Pennsylvania Securities Commission Page 2

Has the firm, business, or company been made aware of this matter?

Yes

If yes, person and title to whom you communicated:

What were the results?

_____________

Name(s) of individual(s) -- Use additional paper if there are several individuals with different addresses.

Address

____________________________________________________________________________________________

City

County

State

Zip Code

(

)

______

Telephone No.

Internet Web Site (if applicable)

2a. Has the individual been made aware of this matter?

Yes

If yes, what were the results?

How long have you dealt with the firm?

year(s)

With the individual(s)?

year(s)

PART D - DESCRIPTION OF COMPLAINT

Date of initial investment: _________________________

Date of most recent investment: _________________________

At the time of your most recent investment, were you age 65 or older? _________________________________________

Describe your complaint in detail, including the events in the order in which they happened and the amount you invested. If

your complaint is against a broker-dealer, include details of what you purchased or sold (e.g., name of stock, number of shares,

and price). If your complaint is against an investment adviser or financial planner, include a detailed description of the nature

of the service involved and the price. Attach additional sheets if necessary. Attach account statements if applicable. Refer to

attached instructions.

Complaint Form - Commonwealth Of Pennsylvania Pennsylvania Securities Commission Page 2