Investor Complaint Form Part 1

Investor Form

SEC Investor Complaint Form part one.htm

Investor Form

OMB: 3235-0547

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 3235-0547 can be found here:

2023-06-20 - Extension without change of a currently approved collection

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SEC Investor Complaint Form

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Investor Complaint Form

You may use this form to send your complaint to the SEC. Although we use secure socket layer encryption, do not hesitate to print this form and send it by mail or fax if you have any concerns about security. Please read our Privacy Act Notice to learn more about how we may use the information you send to us.

Please read our brochure, How We Handle Complaints, for information on what we will do with your complaint, your legal rights, and options for resolving your complaint.

OMB Number:		3235-0547
Expires:	September 30, 2017
Estimated average burden
hours per response:		0.25

Yes, send the form to the firm or company.

No, do not send the form to the firm or company. If you choose "no", we will record your complaint in our database, but we cannot help you any further.

Tell Us About Yourself

	* You must complete this information.
Title
* First name
Middle initial
* Last name
* Street address
Address (cont.)
* City
* State/Province (required if US or Canada)
* Zip/Postal code
* Country
Daytime phone
Alternate phone
Fax
* E-mail
* Are you a

Tell Us About the Firm or Individual You Have a Complaint Against

Firm name
Type of firm
Broker, Advisor, or Salesperson
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country

Tell Us About Your Investment

Type of security
Security symbol
Name of Issuer or Security

Tell Us About Your Complaint

* Please describe your complaint in as much detail as possible, including the full name(s) on the account, the exact type of account, the dates of specific transactions or conversations, the name or ticker symbol of the security(ies) involved, and the names of all the people at the firm you have contacted about this complaint.

What types of documents would you be able to provide us if requested?

Canceled Checks

Correspondence to and from Firm

Advertising or Marketing Materials

Notes of conversation with Firm

Other

Tell Us What Action You Have Taken

Have you complained to the firm? Yes No

Have you contacted any other regulators? Yes No

If yes, whom?

FINRA (Financial Industry Regulatory Authority)

State Regulators

Other Federal Regulators

Foreign Regulators

Stock Exchange

Other

Have you taken legal action? If so, what type:

Mediation

Arbitration

Court Action

Describe the details of the legal action you have taken.

This collection of information has been reviewed by the Office of Management and Budget ("OMB") in accordance with the clearance requirements of 44 U.S.C. §3507. The applicable Privacy Act system of records (SORN) is SEC 65 and the routine uses of the records are set forth at 76 FR 30213 (May 24, 2011). This SORN is exempt from certain sections of the Privacy Act and the citation for the rule exempting the notice is 76 FR 57636 (September 16, 2011).

https://www.sec.gov/oiea/Complaint.html

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