Complaint Form - Indiana Securities Division
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1
2Indiana Secretary of State
Securities Division - Complaint Form
The Indiana Securities Division can investigate possible violations of the following statutes:
Indiana Uniform Securities Act (IC 23-19)
Indiana Loan Broker Act (IC 23-2-5)
Indiana Franchise Act (IC 23-2-2.5)
Indiana Collection Agency Act (IC 25-11)
Indiana Takeover Offers Act (IC 23-2-3.1)
Indiana Commodity Code (IC 23-2-6)
Section 1: Your Information
Name
Date of Birth
County
Street Address
City
State
Zip Code
Daytime Phone
Email Address
Section 2: Select the subject matter that pertains to your complaint
☐ Securities ☐ Loan Broker ☐ Franchise ☐ Collection Agency ☐ Takeover Offers ☐ Commodities
Section 3: Information about the individual and/or business who you believe may have violated the law:
Individual Name
Website
Street Address
City
State
Zip Code
Phone Number
Email Address
Business Name
Website
Street Address
City
State
Zip Code
Phone Number
Email Address
*Note: Please include any additional individuals or businesses in Section 5 “Additional Comments/Details”
Section 4: Transaction/Incident Details
Date of Transaction/Incident
How did you first come in contact with the Individual/Business?
☐ Internet/Email
☐ Printed Advertisement
☐ Word of Mouth
☐ Other _____________
☐ Social Media
☐ Home Visit
☐ Telephone
☐ Yes
☐ No
Have you contacted the Individual/Business regarding your complaint?
What is the dollar amount associated with your loss? [If Applicable]
$
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Parent category: Legal