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Complaint Form. This is a Oklahoma form and can be use in Blue Sky Secretary Of State.
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Tags: Complaint Form, CF, Oklahoma Secretary Of State, Blue Sky
Page 1 of 4
OKLAHOMA DEPARTMENT OF SECURITIES
First National Center, Suite 860
120 North Robinson
Oklahoma City, Oklahoma 73102
Telephone: (405)280-7700 Fax: (405)280-7742
QUESTIONNAIRE
INSTRUCTIONS:
•
•
•
•
Type or print legibly.
Make copies of pertinent information. Do Not Send Originals! Please copy front and back of all checks.
Be specific when describing dates, times, persons, and what statements were made.
If you need more space for an answer, provide the information on additional paper.
INFORMATION ABOUT YOU:
Mr. or
Ms.
Address
DOB:
ST
Place of Employment
Address
Zip
Phone (
)
Phone (
)
Phone(
City
)
Phone (
)
Trade/Occupation
City
ST
Spouse/Partner's Name
Zip
Trade/Occupation
INFORMATION ABOUT THE SELLER:
Business Name
Address
City
ST
Zip
Salesperson
Position
Phone(
)
Other
Position
Phone(
)
Other
Position
Phone(
)
Other
Position
Phone (
)
Did you know the salesperson/company prior to this investment?
No
Yes If Yes, please explain:
INFORMATION ABOUT THE OFFER:
1. How was the offer to invest/purchase made: (Check One) (Attach copies of documents)
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Telephone - Who Called & Date
Personal Visit - Who Visited & Date
Seminar or Group Sales Presentation - Location & Date
Newspaper/Magazine - Name & Date
Other: Explain (Include date)
2. Where was the offer made?
3. Who made the offer?
Position
4. Who else was present? (Name, Address, City, State, Zip Code, Telephone)
(
)
(
)
(
)
INFORMATION ABOUT THE INVESTMENT:
1. Describe the investment offered to you: (Example: Common Stock, Oil and Gas interests, etc.)
2. Did you invest?
3. How did you pay?
No
Cash
Yes When did you invest?
Check (attach a copy-- Front & Back)
Amount invested $
Other
4. How much did you purchase? (Example: 1000 Shares; 5% Working Interest, etc.)
5. Did you sign any type of contract?
No
Yes (attach a copy) Date signed
6. Where was the contract signed/money paid? (City/State)
7. Do you know any other purchasers?
No
Yes (Name, Address, City, State, Zip Code, Telephone)
(
)
(
)
(
)
(
)
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8. What were you told about the investment?
9. What untrue statements, if any, were made to you?
10. What facts, if any, did the seller omit to tell you which would have changed your decision to invest?
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INFORMATION ABOUT YOUR COMPLAINT:
1.
Have you communicated with any other state or federal agency?
No
Yes If Yes, please identify:
a.
b.
c.
2.
Have you hired an attorney?
No
Yes If Yes, please identify: (Name/Address/Telephone)
(
)
3.
Describe your past and current investment experience: (Example: Savings Account, Mutual Funds, Oil & Gas
interests, etc.)
4.
Are you willing to testify in an administrative hearing or court of law regarding this case?
No
Yes
5.
Are you willing to permit the Oklahoma Department of Securities to share information from this Questionnaire
with other government departments and/or law enforcement agencies?
No
Yes
6.
Are you willing to permit the Oklahoma Department of Securities to share information from this Questionnaire to
the firm or party your complaint is against in order to resolve the conflict?
No
Yes
Signature
Date
Signature
Date
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