Form Ipb001 - Complaint Form - New York State Office Of The Attorney Genera Page 2

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Details Regarding the Company And/Or Individual You Are Complaining About
Company Name *
Street Address
Street Address2
City/Town
State
Zip
(ex:12345 or 12345­1234)
County
Phone
Salesperson's Name
(ex:999­999­9999 or 999­999­9999 x9999)
Specifics Regarding Your Complaint
Date of Transaction
Nature of Investment
Total Amount of Investment
Did You Receive the Security You
No
Yes
Purchased?
Fully Explain the Nature of Your Complaint in the Box Below.
Alternatively, You May Upload a Written Description of Your
Complaint as an Attachment to this Form.
What Relief Are You Seeking?

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