Complaint Form - Utah Division Of Securities Page 10
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11BLOCK F: SELF-HELP
Block F(1) -- Complaints To Other Agencies. In connection with the subjec t matter of th is
complaint, have you contacted any other local, stat e, or federal agency? If so, please give this
information below.
Agency Name
Person Contacted
Phone Number
Block F(2) -- Private Legal Action. In connection with the subject matter of th is c omplaint,
have you commenced a lawsuit against any person? If so, please give this information below.
Defendant's Full Name
Court Where Filed
Docket Number
Your Attorney's Name
Law Office
Phone Number
CERTIFICATION
BY SIGNING BELOW, I certify that the information I've provided in this complaint is true to
the best of my knowledge. If the Division of Securities determines that the subject matter of this
complaint is more appropriately within the jurisdiction of another agency of the State of Utah, or
an agency of the U.S. Government, I hereby grant permission to the Division to forward this
complaint to that agency for any action it deems appropriate.
__________________________________________________
_______________________
Complainant's Signature
Date
Continuation Blocks are provided on the reverse side of this page
11
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