Instructions For Completing The Complaint Form - State Of Pennsylvania (Page 4 of 6) in pdf

Instructions For Completing The Complaint Form - State Of Pennsylvania Page 4

If yes, person and title to whom you com m unicated:

W hat were the results?

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

Address

City

County

State

Zip Code

(

)

______

Telephone No.

Internet W eb Site (if applicable)

Has the individual been m ade aware of this m atter?

Yes

If yes, what were the results?

How long have you dealt with the firm ?

year(s)

W ith the individual(s)?

year(s)

PART D - DESCRIPTION OF COMPLAINT

Date of initial investm ent: _________________________

Date of m ost recent investm ent: _________________________

At the tim e of your m ost recent investm ent, were you age 65 or older? _________________________________________

Describe your com plaint in detail, including the events in the order in which they happened and the am ount you invested. If

your com plaint is against a broker-dealer, include details of what you purchased or sold (e.g., nam e of stock, num ber of shares,

and price). If your com plaint is against an investm ent adviser or financial planner, include a detailed description of the nature

of the service involved and the price. Attach additional sheets if necessary. Refer to attached instructions.

Instructions For Completing The Complaint Form - State Of Pennsylvania Page 4