STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DEPARTMENT OF BUSINESS REGULATION SECURITIES DIVISION JOHN O. PASTORE COMPLEX ­ BUILDING 69-1 CRANSTON, RI 02920 401.462-9527 (PHONE) 401.462-9645 (FAX) Office Use Only Case No. ________________ Date Filed _______________ INSTRUCTIONS: Please complete this form and return to above address if you have reason to believe that a licensee regulated by the department has violated the law or failed to meet their responsibilities and obligations to the public. DEPARTMENT COMPLAINT FORM Complainant's Name: Last ________________________________ First_______________________________ Middle_____________ Residence Street___________________________________ City/Town________________________ State_____ Zip______________ Mailing Address (if different from residence)__________________________________________________________________________ Home Telephone________________________________ Business Telephone & Extension____________________________________ Name, Address, Phone of person who always knows where to contact me __________________________________________________ Licensee or regulated activity about whom or which I am making complaint _______________________________________________ Address (Business or Residence) ____________________________________________________ Phone_______________________ Type of Licensee or Regulated Activity Securities Broker Dealer Franchisor Charitable Organizations Fund Raiser ___Investment Adviser ___Time Shares Date, Time and Place of alleged violation__________________________________________________________________________ ____________________________________________________________________________________________________________ Other Federal, State, Municipal, local agencies or legal counsel I have contacted with regard to this complaint, including results of contacts. Explain as fully as possible on the reverse side the exact nature of your complaint against the licensee or regulated activity. Be sure to attach copies of any documentation which will help support your allegations including, but not limited to statements, contracts, purchase agreements, cancelled checks, circulars, prospectuses, advertising, etc. (SEE OTHER SIDE) The undersigned swears to or affirms the truth and accuracy of all statements, answers, representations and allegations contained herein, including all statements hereto attached. SIGNED DATE_________________ A COPY OF THIS COMPLAINT WILL BE FORWARDED TO THE LICENSEE ABOUT WHICH YOU HAVE COMPLAINED. (SEE OTHER SIDE) American LegalNet, Inc. www.FormsWorkFlow.com NATURE OF COMPLAINT: If more space is needed attach additional sheets. The Department will investigate your complaint for possible violations of applicable statutes and regulation. We will make every effort to bring about a satisfactory resolution---this Department only has jurisdiction to take certain statutorily defined regulatory actions against the regulated entity/individual. The Department does not have jurisdiction to order the entity/individual against whom you are filing this complaint to return or refund money to you. Therefore, occasionally, a resolution may not lie within the jurisdiction of this Department. If that is the case, we may suggest you seek an attorney, or refer you to an appropriate agency. If your complaint involves securities, you may also wish to seek arbitration through the FINRA Dispute Resolution, One Liberty Plaza, 165 Broadway, 27th Floor, New York, NY 10006, Telephone (212) 858-4200, Fax (301) 527-4873. . American LegalNet, Inc. www.FormsWorkFlow.com