Utah Division of Securities

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On-line Complaint Form

Information About This Form and the Utah Division of Securities

To submit this form, you must have an e-mail account with the ISP through which you are filing this complaint. Upon receipt of the complaint, efforts will be made to verify the identity of the person submitting the complaint. Anonymous complaints will not be accepted.
It's important for you to fill out each part of this form so that we can fully evaluate your complaint. If a particular part doesn't apply to your situation, please indicate by placing "N/A" (i.e., not applicable) in the appropriate space.
To substantiate your claim we may request that you mail copies of all documents relevant to your complaint -- for example: canceled checks (both sides), contracts, correspondence, prospectuses, sales brochures, etc.
We will treat your complaint as confidential. However, please be advised that under current Utah law your complaint will be subject to release to members of the public under certain circumstances. If you have any questions about this matter, please contact the Division's Records Officer.
If you wish to contact the office by phone, our number is: (801) 530-6600. Our FAX number is (801) 530-6980. Our office is open for your inquires Monday through Friday (except legal holidays), 8:00 a.m. to 5:00 p.m., Mountain Time. Our e-mail address is security@utah.gov.
Please be advised that the Division will not act as your attorney for purposes of recovering a lost investment. Any person who has lost money as the victim of an unlawful securities transaction should immediately contact his or her personal attorney about the possibility of bringing a lawsuit to recover lost funds. If your case involves a violation of the Utah Uniform Securities Act, Utah Code Annotated 61-1-1 et seq., as amended, you may be able to bring a civil action under 61-1-22 of the Act to recover your lost funds (with 12% interest) and reasonable attorney's fees.

Part A: Information About You

First Name:
Last Name:
Home Address:
City, State & Zip:
E-mail:
Home Phone:
Work Phone:

Part B: Information About Your Investment

Nature of Investment - Briefly state what kind of an investment you bought or thought you were buying. For example: stock; bond; note; investment contract; limited partnership; oil, gas or mining title or lease; commodity contract or option, etc. Also indicate the number of shares, items, units, etc. you bought or thought you were buying.
Person Making Initial Contact - Please provide the name, address, phone numbers, and any title and/or company name used by the person who initially contacted you about your investment.
Last Name:
First Name:
Address:
City, State & Zip:
Home Phone:
Work Phone:
Title or Company:
Form of Initial Contact:	Phone Mail E-mail Facsimilie In Person Other	If Other, explain below:
Where Contact Originated - If known, please indicate from where the person above contacted you about the investment
Date of Contact - On what date did the person above initially contact you.
Place of Contact - Where were you when the person above first contacted you about the investment.
Investment Amount:	$
Form of Tender of Payment - In what form did you tender payment for the investment?	Cash Check Money Order Wire Transfer Trade Other	If Other, explain below:
To Whom Payment Was Made - To whom did you make payment for your investment? On what date did you make payment? Where was the payment made or sent to (if made by wire transfer or mail)?
Other Contacts - In connection with the investment, have you been contacted by any other person or office? If so, please give specifics below.

Part C: Why you've made a complaint to the Division

In the space provided below, please explain why you've made this complaint to the Utah Division of Securities. To help organize your thoughts, answer the following two questions: (1) What was the investment deal you made or thought you made?; and (2) If you think you have been treated unfairly as a result of this deal, why do you feel that way? Please give full details of who, what, when, where, why, and how. Try to write down the exact words of persons identified in Block B(2) and B(9). It's better to give too much detail than too little. Please feel free to continue your response on page 8 of this complaint form, if necessary.

Part D: Witness(es) to your story

Do you know of any witness(es) who can verify any of the information you've provided in Block C of this complaint? If so, please provide their names, addresses, and phone numbers below. Also indicate what information they can provide to the Division and whether they were present when the person(s) identified in Part B spoke with you about your investment.

Part E: Other Victims

Do you know of any others who have been victimized in an investment transaction involving persons identified in Part B of this complaint? If so, please give their names, address, and telephone numbers below.

Part F: Self-help

Complaints To Other Agencies - In connection with the subject matter of this complaint, have you contacted any other state or federal agency? If so, please give this information below.

Private Legal Action - In connection with the subject matter of this complaint, have you commenced a lawsuit against any person? If so, please provide the defendant's full name, court where filed, docket number, and attorney's name and law office phone number below.

Certification

BY SUBMITTING THIS FORM, I certify that the information I've provided in this complaint is true to the best of my knowledge. If the Division of Securities determines that the subject matter of this complaint is more appropriately within the jurisdiction of another agency of the State of Utah, or an agency of the U.S. Government, I hereby grant permission to the Division to forward this complaint to that agency for any action it deems appropriate.

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