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Guidelines For Completing The Complaint Form. This is a Idaho form and can be use in Blue Sky Secretary Of State.
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Tags: Guidelines For Completing The Complaint Form, CF, Idaho Secretary Of State, Blue Sky
IDAHO DEPARTMENT OF FINANCE
Securities Bureau
700 West State Street, 2nd Floor
P.O. Box 83720
Boise, ID 83720-0031
Website: idahofinance.com
Fax: 208/332-8099
208/332-8004
GUIDELINES FOR COMPLETING THE SECURITIES COMPLAINT FORM
Before filling out the attached complaint form, please take the time to read these guidelines; they will help you understand our functions, and we will be
better able to understand and act on your complaint.
WHAT WE CAN DO:
We investigate complaints against persons, business entities, and corporations accused of violating the licensing or anti-fraud provisions of laws
administered by the Department. We are empowered to bring administrative or civil actions to stop these violations, and, in appropriate cases, to refer
matters to the Prosecuting Attorneys' offices for criminal prosecution.
WHAT WE CANNOT DO:
We cannot act as a court of law, so we cannot order that monies be refunded, contracts be canceled, damages be awarded, etc. If you have this type of
problem, you should consult an attorney.
We cannot give legal advice or act as your attorney.
HOW YOU CAN HELP US:
The purpose of this complaint form is to provide this Department with enough information to allow us to determine if an investigation into your allegations is
warranted. Thus, it is important for you to furnish as much detailed information as possible.
Documentary evidence is especially important, therefore, you should photocopy all documents such as contracts, agreements, certificates, notes, trust
deeds, correspondence, legible copies of the front and back of checks involved, escrow documents, advertising, etc., and attach them to the written
complaint. (Please do not send originals; we cannot be responsible for their safekeeping.)
Type or print clearly in ink.
If you have any questions concerning this form, you may contact the Securities Bureau at 208/332-8004.
Upon completion of all sections, please mail the form along with your supporting documents to:
Idaho Department of Finance
Securities Bureau
700 West State Street, 2nd Floor
P.O. Box 83720
Boise, ID 83720-0031
Enclosure
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COMPLAINT FORM
INFORMATION ABOUT YOU
A.
Last Name
First
Middle
Today's Date
Home Address
(
City
)
State
Zip
Telephone Number
State
Zip
(
)
Telephone Number
Age
Marital Status
Business Address
City
Trade or Occupation
Are you willing to be interviewed by an investigator from this office?
Yes
No
Are you willing to be a witness if formal proceedings are commenced by the Idaho Department of Finance?
Yes
No
SUBJECT OF COMPLAINT
B.
Company Name
Address
Telephone No.
List persons who were involved in selling you the investment (please use separate pages to set forth any other available information about these
persons.)
Last Name
First
Last Name
Address
First
Position
Telephone No.
City
Address
Middle
State
Zip
Middle
Position
Telephone No.
City
State
Zip
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Please explain in detail your previous investment experience (type, date, amount) with either the company or the salesperson who contacted
you. Additionally, describe any personal relationships/dealings with the company or the salesperson.
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INFORMATION ABOUT INVESTMENT
C.
What did you purchase or invest in? (Examples: common stock, debenture, limited partnership interest, investment contract, fractional interests
in an oil and gas lease). Include the date of purchase, the number of units or shares purchased and the amount paid.
Date of Purchase
Security
No. of Shares
Unit Price
Total Price
Date of Purchase
Security
No. of Shares
Unit Price
Total Price
Date of Purchase
Security
No. of Shares
Unit Price
Total Price
How was the amount paid: (lump sum, installments, other / check, cash, other)
Who received the payment from you?
Did you pay by mail?
To whom did you make your checks payable?
(Please provide a copy of both sides of the check if possible)
D.
In a brief statement, tell us the full story beginning with the date of your first contact to present. Keep dates of events in sequence and include
misrepresentations. Include full names of individuals, including all witnesses present during the transaction(s). Be factual. Try to answer the
questions "who", ''what'', ''where'' and ''when.'' Attach extra sheets if more space is needed.
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E.
How did you learn of the investment? (Check more than one if necessary and enclose copies of pamphlets or advertisements if possible.)
Personal visit
When?
Where?
Whom?
Who else was present?
Telephone call
Date?
From whom?
At what address/location was the call received?
Advertising pamphlet/sales letter
Sent to you at what address/location?
Copy of pamphlet enclosed?
Copy of envelope attached?
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Newspaper
Name of paper?
Date?
Copy of advertisement enclosed?
Radio
Name of station?
Date
Television
Name of station?
Date?
Group Sales Presentation
Date of presentation?
Where?
Others present?
Other (Please Specify)
F.
List others who were present when the offers or sales were made to you.
Name
Telephone
Relationship to Complainant
Name
Address
Telephone
Relationship to Complainant
Name
G.
Address
Address
Telephone
Relationship to Complainant
Did you sign any type of contract?
If so, please enclose a copy.
Where was it signed (city/county)?
Who else was present?
Were your securities delivered?
Where are your securities held?
If your securities have been delivered to you by mail, please attach a copy of the cover letter attached to your securities.
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H.
Who else do you know that invested with the company, corporation, or association?
Name
Address
Telephone
Relationship to Complainant
Name
Address
Telephone
Relationship to Complainant
Name
Address
Telephone
Relationship to Complainant
Name
Address
Telephone
Relationship to Complainant
Name
Address
Telephone
Relationship to Complainant
Name
Address
Telephone
Relationship to Complainant
Name
Address
Telephone
Relationship to Complainant
I.
Yes
Have you complained to subject or seller?
If yes, what offer of adjustment or explanation was made?
No
J.
Have you notified or filed a complaint with any of the following agencies?
U.S. Securities and Exchange Commission
Idaho Attorney General
Local Police Dept.
Other Federal Agency or Office
Better Business Bureau
County Prosecuting Attorney
K.
Sheriff's Office
Local Newspaper
Have you or any other victims filed a lawsuit in any court?
Yes
No
If yes, please provide the name of the case/county/case number and provide a copy of the court documents.
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L.
What would you consider to be a satisfactory solution?
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF IDAHO THAT THE FOREGOING
STATEMENTS AND PHOTOCOPIES OF ATTACHED DOCUMENTS ARE TRUE AND CORRECT.
Signature (Please sign in ink)
Date
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