Securities Complaint Contact Form

Please complete the following information to submit a complaint about a company or individual. The Securities Department will investigate your complaint and, if violations of the law are discovered, your complaint may lead to administrative, civil or criminal action. Your complaint also may be referred to another government agency.

Although the Securities Department may negotiate a rescission offer, it cannot order the return of investor funds. Therefore, you should consult a private attorney regarding your legal remedies.

Your Information

First Name

Middle Name

Last Name

Age

Mailing Address

City

State

Zip Code

County

Country

Home Telephone Number

Work Telephone Number/Ext.

Email Address

Complaint Information

Subject of Complaint

Name of Company/Individual Complaint is About

Check if company name is unknown.

Mailing Address

City

State

Country

Company Web Site

Company/Individual Email Address

Telephone Number/Ext.

How did the company/individual initially contact you?

How much did the company/individual ask you to pay?

How much did you actually pay the company/individual?

How did you pay the company/individual?

Date Company/Individual Contacted You

Provide Complaint Details Please limit your complaint to 5000 characters.

Representative, Salesperson or Individual

First Name

Middle Name

Last Name