Complaint Form. This is a Pennsylvania form and can be use in Blue Sky Department Of State.
Tags: Complaint Form, CF, Pennsylvania Department Of State, Blue Sky
Robert M. Lam, Acting Chairman Thomas A. Michlovic, Commissioner Steven D. Irwin, Commissioner Jeanne S. Parsons, Secretary Michael J. Byrne, Chief Counsel Scott Lane, Deputy Chief Counsel INSTRUCTIONS FOR COMPLETING THE COMPLAINT FORM The Pennsylvania Securities Commission is responsible for regulating securities activities in the Commonwealth of Pennsylvania. We oversee the firms and individuals who offer or sell securities or offer investment advice to the public. Before filling out the attached complaint form, please take the time to read these instructions. They will help you to understand our functions, and we will be better able to understand and act on your complaint. WHAT WE CAN DO: We investigate complaints against individuals, business corporations, and other entities for possible violations of the registration, licensing, or anti-fraud provisions of the Pennsylvania Securities Act of 1972 administered by the Commission. We are empowered to bring administrative actions or civil law suits to stop these violations, render sanctions, and, in appropriate cases, to refer matters for criminal prosecution. It is in the public interest to report alleged violations of the securities laws, and we encourage you to do so. WHAT WE CANNOT DO: We cannot act as a court of law. We cannot order that monies be refunded or that damages be paid. In some instances restitution or rescission is made to investors as a result of this agency’s action, but those instances are not the norm. YOU SHOULD NOT RELY ON US TO GET YOUR MONEY BACK FOR YOU. We cannot enforce the Business Corporation Laws, partnership laws, contract laws, or regulate the offer and sale of annuities. We cannot give legal or financial advice or act as your attorney. HOW YOU CAN HELP US: Organize your complaint using these guidelines: 1. First, make a separate list of the things you want to say. Separate your feeling from the facts. 2. In Part D of this form, present the events in the order in which they happened, using dates whenever possible. a. b. c. d. e. f. g. Tell us WHAT happened. Start from the beginning. Be specific as to what was said and who said it. Tell us HOW you first learned of the investment opportunity or investment service. Tell us WHO was present during these conversations or acts. Tell us WHEN and WHERE these conversations/acts took place. Tell us WHEN and WHERE the money and agreements changed hands. Tell us WHY you decided to take advantage of the investment or investment service. List the names, addresses, and telephone numbers of any others who you believe may have similar complaints. 3. Type or print clearly in ink. 4. Enclose copies of documents such as stock certificates, bonds, limited partnership agreements, prospectuses, confirmations, account statements, letters, cancelled checks (front and back), advertisements, papers, notes, or other documents that may explain your complaint. Do not send originals; we cannot be responsible for their safekeeping. 5. Remember that your complaint should describe the event or practice which you believe was unfair. If possible, you should state why the event or practice was improper. Eastgate Office Building | 2nd Floor | 1010 North Seventh Street | Harrisburg, PA 17102-1410 Toll Free in PA: 1.800.600.0007 | Telephone: 717.787.8061 | Fax: 717.783.5122 | Web: www.psc.state.pa.us TDD/AT&T Relay Center: 1.800.654.5984 American LegalNet, Inc. www.FormsWorkFlow.com STEPS YOU CAN TAKE IF YOUR COMPLAINT INVOLVES A BROKER-DEALER: Many disputes with brokerage firms can be directly resolved by your doing the following: NOTIFY YOUR BROKER AND YOUR BROKER’S MANAGER 1. Talk to your salesperson about the problem. 2. Negotiate directly with your salesperson to resolve the matter. Frequently, minor issues can be settled informally at this point. 3. If you feel the salesperson has answered your questions unsatisfactorily or is unwilling to review your complaint, contact the salesperson’s supervisor, as well as the office manager. 4. Write to the firm’s chief compliance officer. This individual is located at the firm’s home office address. Request a response in writing from the compliance officer. (You can get the name of the compliance officer and the firm’s home address from the broker’s office.) ARBITRATION PROCEDURES The United State Securities and Exchange Commission has approved certain arbitration procedures for resolution of disputes between investors and broker-dealers. Arbitration is a method of having a dispute between two or more parties resolved by an impartial person who is knowledgeable in the areas of controversy. Arbitration generally is quicker and less expensive than using the courts to resolve a complaint. Because of this, arbitration has long been used as an alternative to the courts. Once the arbitrator has made a decision, the decision is final and is subject to review by a court only on a very limited basis. Also, if arbitration is chosen as a means of resolving a dispute, the complaining party gives up the right to pursue the matter through the courts. Further, based upon the contract entered into between you and your broker, you may be obligated to submit the dispute to arbitration in lieu of litigation through the courts. If you are interested in learning more about the arbitration process, you can contact the Financial Industry regulatory Authority (FINRA). The address for FINRA is: Financial Industry Regulatory Authority 1835 Market Street Philadelphia, PA 19103 Telephone: (215) 665-1180 If you have any questions concerning this form, you may call the Pennsylvania Securities Commission in Philadelphia, (215) 5602088; in Harrisburg (717) 787-8061; or in Pittsburgh (412) 565-5083, between 8:30 a.m. and 5:00 p.m. Upon completion of all sections, please mail the complaint form along with copies of any supporting documents to: Pennsylvania Securities Commission ATTN: Office of Secretary 1010 N. Seventh Street, 2nd Floor Eastgate Office Building Harrisburg, PA 17102-1410 PLEASE NOTE: As part of the complaint handling process, the Commission may send a copy of this form to the brokerdealer firm against whom your complaint is filed. American LegalNet, Inc. www.FormsWorkFlow.com COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA SECURITIES COMMISSION COMPLAINT FORM Please review the attached instruction before completing this form. This complaint is being filed on behalf of: Self (Skip Part A; proceed directly to Part B) Someone Else (Complete entire form, starting with Part A) PART A – FILER’S INFORMATION (Complete Part A if you are filing this Complaint on behalf of someone other than yourself. Otherwise, skip Part A and proceed directly to Part B.) Your Last Name First Middle Initial Your Street Address (Number and Name) (Apt No.) City County State ( ) Home Telephone No. ( ) Work Telephone No. ( ) Cell Phone No. Zip Code Email Address Relationship to Investor PART B – INVESTOR’S INFORMATION Investor’s Last Name First Middle Initial Investor’s Street Address (Number and Name) (Apt No.) City County State ( ) Home Telephone No. ( ) Work Telephone No. Zip Code Relationship to Investor PART C – COMPLAINT IS AGAINST: Firm, business or company Individual 1. Name of firm, business, or company Address City ( County State Zip Code ) American LegalNet, Inc. www.FormsWorkFlow.com Telephone No. 1a. Internet Web Site (if applicable) Has the firm, business, or company been made aware of this matter? Yes No If yes, person and title to whom you communicated: What were the results? 2. Name(s) of individual(s) – Use additional paper if there are several individuals with different addresses. Address City County State ( ) Telephone No. Internet Web Site (if applicable) 2a. Yes Zip Code Has the individual been made aware of this matter? No If yes, what were the results? 3. How long have you dealt with the firm? year(s) With the individual(s)? year(s) PART D – DESCRIPTION OF COMPLAINT Date of initial investment: Date of most recent investment: At the times of your most recent investment, were you age 65 or older? Describe your complaint in detail, including the events in the order in which they happened and the amount you invested. If your complaint is against a broker-dealer, include details of what you purchased or sold (e.g., name of stock, number of shares, and price). If your complaint is against an investment adviser or financial planner, include a detailed description of the nature of the service involved and the price. Attach additional sheets if necessary. Attach account statements if applicable. Refer to attached instructions. American LegalNet, Inc. www.FormsWorkFlow.com PART E – RESOLUTION 1. How do you want this dispute resolved? American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com 2. Have you brought this complaint to the attention of others? Please check box(es) as appropriate. U.S. Securities and Exchange Commission Financial Industry Regulatory Authority Philadelphia Stock Exchange American Stock Exchange New York Stock Exchange Commodity Futures Trade Commission NASDAQ 3. If necessary, are you willing to appear as a witness, be sworn, testify and be cross-examined concerning the allegations made in this complaint? Consumer protection agency – If so, which one? District Attorney – If so, which one? Your attorney – identify: Other – identify: Yes No If no, why not? I have read this complaint, I fully understand its contents, and I certify that it and photocopies of attached documents are true and correct to the best of my knowledge and belief. Signature Date Return completed form and photocopied documents to: PENNSYLVANIA SECURTIES COMMISSION 1010 N. SEVENTH STREET, 2ND FLOOR EASTGATE OFFICE BUILDING HARRISBURG, PA 17102-1410 Attn: Office of Secretary Visit the Pennsylvania Securities Commission’s website at www.psc.state.pa.us for investor information, news releases, enforcement actions, and much, much more! American LegalNet, Inc. www.FormsWorkFlow.com