Tell Us About the Firm or Individual You Have a Complaint Against
Firm name Type of firm Broker, Advisor, or Salesperson Street address Address (cont.) City State/Province Zip/Postal code Country Tell Us About Your Investment
Type of security Security symbol Name of Issuer or Security Tell Us About Your Complaint
* Please describe your complaint in as much detail as possible, including the full name(s) on the account, the exact type of account, the dates of specific transactions or conversations, the name or ticker symbol of the security(ies) involved, and the names of all the people at the firm you have contacted about this complaint.
What types of documents would you be able to provide us if requested?
Canceled Checks
Correspondence to and from Firm
Advertising or Marketing Materials
Notes of conversation with Firm
Other Tell Us What Action You Have Taken
Have you complained to the firm? Yes No Have you contacted any other regulators? Yes No
If yes, whom?
FINRA (Financial Industry Regulatory Authority)
State Regulators
Other Federal Regulators
Foreign Regulators
Stock Exchange Other
Have you taken legal action? If so, what type:
Mediation
Arbitration
Court Action
Describe the details of the legal action you have taken.
This collection of information has been reviewed by the Office of Management and Budget ("OMB") in accordance with the clearance requirements of 44 U.S.C. §3507. The applicable Privacy Act system of records (SORN) is SEC 65 and the routine uses of the records are set forth at 76 FR 30213 (May 24, 2011). This SORN is exempt from certain sections of the Privacy Act and the citation for the rule exempting the notice is 76 FR 57636 (September 16, 2011).
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