STATE OF CALIFORNIA -- BUSINESS, TRANSPORTATION AND HOUSING AGENCY DEPARTMENT OF CORPORATIONS Complaint Form Instructions If you have questions about this form, please call our Consumer Services Office: (916) 327-7585 or toll-free at (866) ASK-CORP (1-866-275-2677) What the Department Does: In general, the Department of Corporations licenses and regulates: • • • • • Securities professionals (broker-dealers, investment advisers, financial planners); Finance lenders, mortgage loan servicers, and certain mortgage lenders and mortgage brokers; Bill payers, check sellers, and proraters (consumer credit counselors, debt management companies); Payday lenders; and Escrow companies and agents. The Department of Corporations also regulates: • • The offer and sale of franchises and certain investments (securities); and Off-exchange commodities transactions. Complaints submitted to the Department are reviewed to determine whether investigation and possible enforcement action may be warranted. Do not, however, view a complaint to the Department as a substitute for pursuing private legal remedies. Consult a private attorney if money needs to be recovered or a contract needs to be cancelled. Please submit a complaint to the Department even if the dispute is being pursued through another resource. The Department relies on complaints from the public to enforce the laws under its purview and to provide oversight of the companies it regulates. If a complaint is submitted to the Department that is not within our jurisdiction, we will refer the complaint to the appropriate agency. How You Can Help Us: When submitting a complaint, please follow these steps: • Clearly state WHAT happened, WHO was involved, and WHEN and WHERE the events occurred. Please provide any other relevant information that may assist us in understanding and resolving your complaint including amounts invested and/or lost. • Provide copies of all documentation. Do not send originals. • Type or print clearly in ink. • Sign the form. • Mail the form and documentation to: Department of Corporations Consumer Services Office 1515 K Street, Suite 200 Sacramento, CA 95814 DOC 29 (Rev. 11/08) American LegalNet, Inc. www.FormsWorkflow.com STATE OF CALIFORNIA -- BUSINESS, TRANSPORTATION AND HOUSING AGENCY DEPARTMENT OF CORPORATIONS Complaint Form Instructions Page 2 of 2 NOTICE REQUIRED UNDER STATE LAW The following notice is required by state law under the Information Practices Act of 1977 (California Civil Code Section 1798.17). The California Department of Corporations requests the information in the attached form to determine whether: • • • a license, qualification, registration, certificate or other authority should be accepted, granted, approved, denied, revoked, or limited in any way; business entities or individuals licensed or otherwise regulated by the Department of Corporations are conducting themselves in accordance with applicable laws; and/or laws administered by the Department of Corporations are being or have been violated and whether administrative action, civil action, or referral to a self-regulatory organization or other government agency is appropriate as authorized by law. All information you provide is voluntary. Failure to provide all or any part of the information requested may preclude the Department of Corporations from investigating your complaint. We may share your personal information, as needed, with licensed business entities or individuals to facilitate resolution of your complaint. We may also share your information with other government agencies or self-regulatory organizations as authorized by law. The information you provide is maintained by the Department of Corporations pursuant to one or more of the following laws: • • • • • • • • • • • Corporate Securities Law of 1968 (Corporations Code Section 25000, et seq.); Capital Access Company Law (Corporations Code Section 28000, et seq.); Bucket Shop Law (Corporations Code Section 29000, et seq.); California Commodity Law of 1990 (Corporations Code Section 29500, et seq.); Franchise Investment Law (Corporations Code Section 31000, et seq.); Check Sellers, Bill Payers and Proraters Law (Financial Code Section 12000, et seq.); California Deferred Deposit Transaction Law (Financial Code Section 23000, et seq.); Escrow Law (Financial Code Section 17000, et seq.); California Finance Lenders Law (Financial Code Section 22000, et seq.); Securities Depository Law (Financial Code Section 30000, et seq.); and California Residential Mortgage Lending Act (Financial Code Section 50000, et seq.). You have a right to see your personal information. The official responsible for maintaining information gathered by the Department of Corporations is: Deputy Commissioner, Office of Management and Budget Department of Corporations 1515 K Street, Suite 200 Sacramento, California 95814-4052 (916) 445-5541 DOC 29 (Rev. 11/08) American LegalNet, Inc. www.FormsWorkflow.com STATE OF CALIFORNIA -- BUSINESS, TRANSPORTATION AND HOUSING AGENCY DEPARTMENT OF CORPORATIONS Complaint Form Page 1 of 2 Complaint Form 1. Your Information (type or print clearly): Mr. Miss Ms. Mrs. Print Your Full Name (First, MI, Last) Your Home Address (Street, City, State and Zip Code) Your Business Address (Street, City, State and Zip Code) Business Phone Home Phone Daytime Phone E-mail Address Your age (please check one): Under 50 50 – 64 65 and Over For Military Personnel Only: Branch of Service Rank Base Address (where you are stationed) 2. Information on the individual or organization about which you have a complaint: Full Name of Business, Company, Firm, or Person Street Address of Business, Company, Firm or Person (include Room #, Suite #, or Apt. #, if any) City State Zip Code Business Phone Full Name of Salesperson, Agent or Other Representative (if applicable) Employer of Salesperson, Agent or Other Representative (if different than Business Name above) DOC 29 (Rev. 11/08) American LegalNet, Inc. www.FormsWorkflow.com STATE OF CALIFORNIA -- BUSINESS, TRANSPORTATION AND HOUSING AGENCY DEPARTMENT OF CORPORATIONS Complaint Form Page 2 of 2 3. Have you already directly contacted the business, firm or individual(s) regarding your complaint? Yes No If yes, include the names of the persons contacted and the dates you contacted them; attach copies of all documents relating to this correspondence. If necessary, attach extra pages. Name of Person(s) Contacted Date(s) Contacted What was the result of the contact (if any)? 4. Have you filed a lawsuit or arbitration regarding this complaint? Lawsuit Arbitration Neither 5. Briefly describe your complaint. Answer the questions of “who,” “what,” “where” and “when.” Include the full names, addresses, and telephone numbers of any witnesses present during the transactions, and dollar amounts invested and/or lost. If necessary, attach extra pages. 6. What do you believe would be a fair resolution to this matter? 7. How did you find out about the Department of Corporations? Seniors Against Investment Fraud (SAIF) Troops Against Predatory Scams (TAPS) Other (please state) 8. Attach a copy of all written correspondence and documentation related to your complaint. 9. SIGNATURE In filing this complaint, I agree the information provided is true and correct to the best of my knowledge and that the information may be used by the Department to further investigate my complaint. I understand that the Department of Corporations’ investigations are generally confidential and in some cases it is necessary for the Department to send my complaint to the licensee. ___________ Date ___________________________________________ Signature DOC 29 (Rev. 11/08) American LegalNet, Inc. www.FormsWorkflow.com