Washington State Department of Financial Institutions

Online Complaint Form

Washington State Department of Financial Institutions
Securities Division, PO Box 9033, Olympia, Washington 98507-9033
Phone:(360)902-8760; 1-877-RING DFI (1-877-746-4334); FAX:(360)902-0524

Please answer every question completely. You may want to write your answers on a separate sheet first, then enter them in the blanks on this report.

When finished filling out the report, click on the Submit button at the bottom of this page. Your complaint will be sent to the Securities Division. (See Documents section for instructions on sending any supporting documents.)


YOUR INFORMATION

Your Name
Birth Date
Address
City
State
Zip Code
Telephone # (day)
Telephone # (night)
Best Time to Call
Email Address
Occupation

COMPLAINT AGAINST

Name of Business
Person you dealt with
Address
City
State
Zip Code
Telephone #
Business E-mail or Website Address

Names, addresses, and phone numbers of any other businesses or persons
involved in your complaint.

How and when did you first hear about this investment?

How much money did you invest?

What date(s)?

How did you deliver the payment (e.g., mail, FedEx)?

What kind of investments did you buy?

How and when did the person first contact you?

Please list any courier or postal service used by the person to contact you and when that contact occurred.

How did you pay the company for the investment
(e.g., personal or cashier's check, cash, wire transfer)?

I have complained to the person or firm.

If you checked the box above, please describe. (Was your complaint in writing or did you speak to someone? If in writing, please send a copy of the complaint. If you talked to someone, who was it and when did it happen?)


I have contacted another regulator or taken legal action.

If you checked the box above, please describe.

EXPLAIN YOUR COMPLAINT IN DETAIL

Please provide a detailed explanation of the facts that led to your complaint. Start at the beginning and continue through to the present. Be sure to include AT LEAST the following information: How, when, and from whom did you first hear about this investment? What verbal and/or written information did you receive about the investment? Did you later find that any of this information was untrue?

DOCUMENTS

Please make copies of any documents or written materials relating to your complaint. If it involves brokerage accounts, please make copies of the brokerage statements showing the transaction(s), and send all the copies to us. Please be sure to include copies of the front and back of any investment-related check. We will ask you for the originals if we need them.

If you file your complaint online, please mail supporting documents to: Securities Division, PO Box 9033, Olympia, WA 98507-9033. Include a cover letter stating that you have sent your complaint using the online complaint form. If you send materials you want returned, please indicate in your cover letter what you want returned.

OTHER INVESTORS

Do you know anyone else who purchased the investment that is the subject of this complaint? If so, please list their names, addresses, and phone numbers, or as much information as you can.

PUBLIC RECORDS DISCLOSURE ACT

Under the public records provisions of Washington law, RCW 42.17 et seq., this complaint may become subject to public disclosure at some time after the investigation is ended.

If you do not want this report sent to the subject of your complaint please explain here.

By checking this box, I request this complaint not be disclosed if it is requested pursuant to the Public Records Disclosure Act.

Declaration: By filling in my name and the date below, I declare that the information contained in this complaint is true and accurate and the information may be used to further investigate the complaint.
Name:
Date: