State of Utah BD/ADVISOR COMPLAINT DEPARTMENT OF COMMERCE Division of Securities 160 East 300 South, 2nd Floor P.O. Box 146760 Salt Lake City, Utah 84114-6760 DISPOSITION: • Not Assigned • Investigator: • Case #: Phone: 801 530-6600 Fax: 801 530-6980 ____________________________________________________________________________ COMPLAINT FORM Please complete this form and attach any documents (ie. Photo copies of account statements, transaction confirmations, any correspondence or notes from conversation) that may be pertinent to your complaint. If you have any questions or need assistance in completing this form, feel free to contact the Division of Securities. We will proceed with a preliminary review as soon as this form is returned. PERSONAL INFORMATION A broker or investment advisor has a fiduciary responsibility to provide investments which are suitable to your personal financial needs. The personal financial information you provide will be treated as confidential by the Division, but will be subject, in certain instances, to disclosure as provided by law. The Division may disclose the substance of your complaint to those responsible for answering the claims made by you. _________________________________________________________ LAST NAME FIRST MI ____________________________________________________________________________ HOME ADDRESS CITY, STATE ZIP PHONE ___________________________________________________________________________________________ BUSINESS ADDRESS CITY, STATE ZIP PHONE ___________________________________________________________________________________ E-MAIL ADDRESS CELL PHONE Please check applicable boxes (as of the time of investment): Age Net Worth (exclusive of home) Net Income Tax Bracket Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ 65 or Older 45 to 65 31 to 44 18 to 30 Business $0-50,000 $50,000-100,000 $100,000-250,000 $250,000-500,000 >$500,000 $0-20,000 $20,001-50,000 $50,001-100,000 $100,001-250,000 > $250,000 0% 15% 28% 36% 39.6% American LegalNet, Inc. www.FormsWorkflow.com INVESTMENT INFORMATION ________________________________________ _________________________ _____________ BROKERAGE OR INVESTMENT ADVISOR FIRM BROKER/REPRESENTATIVE ACCOUNT # BRANCH ADDRESS CITY, STATE ZIP PHONE Please check applicable boxes (as of the time of investment): Account Type Prior Trading Experience Investment Objective (Please Rank) Liquidity Time Horizon Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Tax Deferred Regular Acct. Custodial Options Margin Stocks Bonds Mutual Funds Options Commodities Foreign Securities Safety of Principal Tax Free Income Income Growth Trading Speculation 0-6 Months 6-12 Months 1-2 Years 2-5 Years 5-10 Years > 10 Years Type of Investments Made: (Please check the box for applicable investments made) Bonds: Ƒ Ƒ Ƒ Ƒ Ƒ Money Market U.S. Gov. T-Bills U.S. Gov. Notes U.S. Gov. Bonds U.S. Gov. Agency Bonds Stock: Ƒ Ƒ Ƒ Ƒ Preferred Stock Blue Chip Stock (eg. IBM) Small Cap Stock (NASD Mkt.) International Stock Speculation Ƒ Options Ƒ Short Sales Ƒ Penny Stock Ƒ Precious Metals Ƒ Commodities Ƒ Ƒ Ƒ Ƒ Ƒ Tax Free Muni (A rated or higher) Tax Free Muni (Baa rated or lower) Corporate Bonds (A rated or higher) Corporate Bonds (Baa rated or lower) Convertible Bonds Mutual Funds & Partnerships: Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Gov. Bond Funds GNMA Bond Fund Tax Free Muni Bond Fund Corporate Bond Fund Corp. Junk Bond Fund Blue Chip Stock Fund Growth Stock Fund Balanced Fund (Stocks & Bonds) International Stock Fund International Bond Fund Limited Partnerships American LegalNet, Inc. www.FormsWorkflow.com General Questions: Yes No N/A Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Were purchases in the account solicited, or recommended by the broker? Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Ƒ Was investment risk discussed prior to purchase? Were trades made in your account without your authorization? Did you receive a prospectus prior to the purchase of a mutual fund, limited partnership, or an initial public offering? Do you feel the purchases were in line with your investment goals? Did you have the financial ability to absorb the risk of the investment? Did you understand the risks of the investment? Did your account have a margin agreement? Did your broker or investment advisor have power of attorney? Nature of Complaint: Explain in your own words what you think was done wrong. How do you feel you have been injured by the acts of your broker or advisor? What was done? Who was involved? The date or period of time the problem arose? (if further space is required, please enclose an attachment) _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com Were any other persons present when the investment opportunity was explained to you? (Please list their names and addresses) _________________________________________________________________________________________ NAME HOME ADDRESS CITY, STATE ZIP PHONE _________________________________________________________________________________________ NAME HOME ADDRESS CITY, STATE ZIP PHONE Do you know of anyone else who has invested in the same company or business or who invested through the same salesperson? _________________________________________________________________________________________ NAME HOME ADDRESS CITY, STATE ZIP PHONE _________________________________________________________________________________________ NAME HOME ADDRESS CITY, STATE ZIP PHONE Transactions in Question: If the entire account is in question or there have been more than 5 questionable trades, please enclose account statements with the questionable trades marked. Date of Purchase Investment Shares/Units Invested Amount Invested Gain Loss _______________ _______________ ______________ _______________ ____________ _______________ _______________ ______________ _______________ ____________ _______________ _______________ ______________ _______________ ____________ _______________ _______________ ______________ _______________ ____________ _______________ _______________ ______________ _______________ ____________ Yes No Ƒ Ƒ Ƒ Ƒ Have you filed a complaint with the brokerage or investment advisory firm in question? Ƒ Ƒ Have you obtained legal counsel? Please Specify: ____________________________________ Have you filed this complaint with any other agency? (Securities and Exchange Commission, National Association of Securities Dealers, Inc. NASD, Police, Better Business Bureau) Please Specify: _____________________________________________________________________ Please attach copies of all documents to help us better understand your complaint. PLEASE SIGN AND DATE: ________________________________________ SIGNATURE __________________________________ DATE THANK YOU FOR TAKING THE TIME TO COMPLETE THIS FORM American LegalNet, Inc. www.FormsWorkflow.com