Form OMMS Form OMMS Form OMMS Form

Ombudsman Matter Management System

Data Fields

‘About You’ section:

Are You a Retail (Individual) Investor?

 Yes

 No

Do You Wish to Report Anonymously?

 Yes

 No

May We Contact other U.S. Securities and Exchange Commission (SEC) Divisions/Offices, Self-Regulatory Organizations, individuals and/or other entities regarding this Matter?

 Yes, you may contact other SEC Divisions/Offices, Self-Regulatory Organizations, individuals and/or other entities regarding this matter

 No, do not contact other SEC Divisions/Offices, Self-Regulatory Organizations, individuals and/or other entities regarding this matter

Prefix [dropdown menu options: Mr., Ms., Mrs., Dr., Rev., The Honorable]

First Name [fillable text field]

Middle Name [fillable text field]

Last Name [fillable text field]

Address [fillable text field]

City [fillable text field]

Country [dropdown menu of country options]

State/Province [dropdown menu options dependent on country selection]

Zip/Postal Code [fillable text field]

Primary Phone Number [fillable text field]

Alternate Phone Number [fillable text field]

Primary Email [fillable text field]

Secondary Email [fillable text field]

‘Your Matter’ section:

Is Your Matter About the U.S. Securities and Exchange Commission (SEC)?

 Yes

 No

If Yes, Please Select the SEC Office(s) or Division(s)

[Multi-select dropdown menu options list SEC Divisions and Offices]

Is Your Matter About a Self-Regulatory Organization (SRO)?

 Yes

 No

If Yes, Please Select the Self-Regulatory Organization(s) (SROs)

[Multi-select dropdown menu options list Self-Regulatory Organizations]

‘Entity(ies)/Individual(s) Involved’ sub section:

Entity Name [fillable text field]

Entity Phone [fillable text field]

Entity Website [fillable text field]

Address [fillable text field]

City [fillable text field]

Country [dropdown menu of country options]

State/Province [dropdown menu options dependent on country selection]

Zip/Postal Code [fillable text field]

Individual First Name [fillable text field]

Individual Last Name [fillable text field]

Job Title [fillable text field]

Mobile [fillable text field]

Fax [fillable text field]

Email [fillable text field]

‘Your Matter’ section continued:

What is Your Matter About? [Multi-select dropdown menu options choices: Collateralized Mortgage Obligations (CMOs), Debt Securities/Bonds, Equity Security/Stock, Exchange Traded Funds (ETFs), Foreign Securities, Hedge Funds, Initial Public Offerings (IPOs), Lower-rated and “junk” Bonds, Money Market Accounts, Mortgage-Backed Securities, Municipal Bonds, Mutual Funds, Options, Ponzi/Pyramid Schemes and Multi-level Marketing Organizations, Retirement Accounts, U.S. Government Securities/Agency Issues, Unit Investment Trust (UITs), Variable Annuities, and Other]

Name of Issuer or Security [fillable text field]

Security Ticker Symbol [fillable text field]

Describe Your Matter in Detail [fillable text field]

What additional documents can you provide if requested [Multi-select dropdown menu options choices: Advertising or Marketing Materials, Written Materials, Emails, and Notes of Conversation]

‘Have You Already’ section:

Contacted the SEC Before About This Matter?

 Yes

 No

If Yes, Which SEC Division(s)/Office(s) Did You Contact?

[Dropdown menu options list SEC Divisions and Offices]

Submitted a Tips, Complaints and Referrals (TCR) Questionnaire, Investor Inquiry Form, and/or Investor Complaint Form to the SEC Relating to This Matter?

 Yes

 No

If yes, do you have a TCR Number, or Other ID or Reference Number relating to this Matter?

[fillable text field]

Contacted any Self-Regulatory Organizations (SROs) Directly?

 Yes

 No

Contacted Any Other Regulators And/Or Law Enforcement Agencies Directly?

 Yes

 No

If Yes, Which Regulators And/Or Law Enforcement Agencies? [Multi-select dropdown menu options choices: State Regulators, Other Federal Regulators, and Foreign Regulators]

Taken Any Legal Action?

 Yes

 No

If So, What Type of Legal Action? [Multi-select dropdown menu options choices: Mediation, Arbitration, Court Action, and Other (includes fillable text field)]

Please provide additional details [fillable text field]

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