Securities and Investment Complaint Form

Public Records Disclosure Act *

Keep Information Exempt

Do Not Keep Information Exempt

The Washington Public Records Act (PRA), RCW 42.56, may require disclosure of a complaint after a file is closed. If you choose, you may keep your identifying information exempt from disclosure under the PRA. Please note that this exemption does not necessarily restrict the release of your identifying information pursuant to a court order, subpoena, or during litigation.

Whistleblower Award and Protection Act

Please select this option if you wish to be considered a whistleblower under the Whistleblower Award and Protection Act, chapter 21.40 RCW. An individual who makes a whistleblower complaint may be eligible to receive an award based on the amount of monetary sanctions collected in an action brought by the Securities Division as a result of the information provided. An individual that wishes to make an anonymous whistleblower complaint must be represented by counsel. Prior to the payment of an award, an anonymous whistleblower must disclose their identity to the Securities Division although their identity is protected from public disclosure pursuant to RCW 42.56.400(6). Individuals that make whistleblower complaints or that report potential securities law violations to their employer are protected from retaliation pursuant to the Act.

Your Information

Name *

Birthdate *

Mailing Address *

City *

State *

Zip Code *

Phone Number *

Best Time to Call

Fax Number

Email Address *

Your Complaint is Against the Following Business

Business Name *

Business Address

Business City

Business State *

Business Zip

Business Phone

Who You Dealt With

Business Email

Business Website

Names

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

Additional Information

How and when did you first hear about this investment?

How much money did you invest?

What dates?

What kind of investment(s) did you buy?

How did you pay for your investment(s)?

What method did you use to deliver the payment?

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 the contact occurred.

Have you complained to the person or firm? If yes, 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 spoke with a person, who was it and when did it happen?

Have you contacted any other regulator or taken any legal action? If yes, please describe.

Complaint in Detail *

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, phone numbers.

Jurisdiction of the Securities Division

The jurisdiction of the Securities Division generally extends only to issues connected with the initial offer and sale of securities, franchises, business opportunities, and commodities. We may not have jurisdiction if your complaint involves later actions by management that you think are unfair to investors, or in actions by management such as the failure to hold shareholder meetings or provide annual reports. However, you may have civil remedies available to address your complaint, so please consult your attorney. Also, the Division does not have the authority to represent you in civil litigation, which means you must hire your own attorney to recover your investment funds.

Declaration

By filling in my name and the date below, I declare, under penalty of perjury under the laws of the State of Washington that the information contained in this complaint is true and accurate and the information may be used to further investigate the complaint.

Declaration Name *

Declaration Date *