Complaint Form - Securities Bureau {CF}

COMPLAINT FORM Securities Bureau PLEASE COMPLETE THE COMPLAINT FORM AND MAIL IT TO OUR OFFICE. KEEP A COPY FOR YOUR RECORDS. Nebraska Department of Banking & Finance Securities Bureau - Complaints P.O. Box 95006 Lincoln, Nebraska 68509-5006 GUIDELINES FOR COMPLETING THE COMPLAINT FORM The Complaint Form may be completed using a computer (except for signatures) or by printing a copy of the form and typing or printing clearly in ink. After you have entered all necessary data, please sign and date the form and return it to the above address. WHAT WE CAN DO We investigate complaints against individuals, business entities, and corporations accused of violating the licensing or anti-fraud provisions of laws administered by the Department. We are empowered to bring administrative or civil actions to stop these violations, and, in appropriate cases, to refer matters to the proper authorities for further investigation and/or criminal prosecution. Please refer to the Securities Bureau Page for types of entities regulated by the Department. We investigate complaints for alleged violations of the following laws: Nebraska Commodity Code, Securities Act of Nebraska, Loan Brokers Act, Seller-Assisted Marketing Plan Act, Consumer Rental-Purchase Agreement Act. WHAT WE CANNOT DO We cannot act as a court of law to resolve factual disputes. We cannot order monies be refunded, contracts be cancelled, damages be awarded, etc. If you have this type of problem, you should consult a private attorney. We cannot give legal advice or act as your attorney. If this dispute is the subject of a lawsuit, we cannot intervene in the matter. Please fill out the form by typing or printing clearly in ink. Sign the form and return it to the address above. Keep a copy for your files. Rev. 5/2011 1 American LegalNet, Inc. www.FormsWorkFlow.com SECTION I - CONSUMER INFORMATION Your name: (Last, First, MI) Your daytime phone: (include area code) Your street address: (if different from mailing address, please note) City: State: Zip code: Your email address if applicable: SECTION II - COMPANY/INDIVIDUAL INFORMATION Name of the company/individual: Business address: Business phone: (include area code) City: State: Zip code: Rev. 5/2011 2 American LegalNet, Inc. www.FormsWorkFlow.com SECTION III - NATURE OF THE PROBLEM Briefly describe the nature of your complaint and the events in the order in which they happened, including specific dates, and the company's/individual's actions to which you objected. Enclose COPIES of any pertinent information or correspondence that may be helpful. DO NOT SEND ORIGINALS; DO NOT SEND YOUR ONLY COPY OF ANY DOCUMENT. Keep a copy of this document for your own files. (If additional space is needed, please attach a separate sheet and reference it accordingly.) Have you attempted to resolve your complaint directly with the company/individual? Yes Name of person(s) contacted: No Date(s) contacted: Company's/individual's response: (If additional space is needed, please attach a separate sheet, and reference it accordingly.) Rev. 5/2011 3 American LegalNet, Inc. www.FormsWorkFlow.com PRIVACY STATEMENT The information requested on this form will be used to investigate and respond to your complaint. In our efforts to resolve your issue, this information may be disclosed outside of our agency to the company/individual which is the subject of your complaint; to any involved third parties; to the federal agency that has supervisory authority over the company/individual; to appropriate federal, state or local law enforcement authorities if a violation or possible violation of civil or criminal law is discovered; or to a legislative office in response to any inquiry made at your request. Information obtained in the course of an investigation will be considered confidential which will be disclosed only pursuant to a valid subpoena or as set forth above. DISCLOSURE I wish to file a complaint against the company/individual named in this complaint form, with the understanding that the Bureau may conduct an investigation on my behalf. However, I understand that the Bureau does not have the authority to act as a judge in factual disputes. I understand that completion of this form is voluntary, but failure to provide requested information and/or failure to sign this form may delay or preclude investigation of my complaint. I understand that, as a part of the investigation on my behalf, a copy of this form may be forwarded to the company/individual mentioned in the complaint. I further understand that the Bureau, as part of its investigation, may require access to my financial records related to this complaint. I hereby authorize the custodian of such records to provide copies of my financial records to the Bureau in connection with its investigation. Signature Date: (required): Rev. 5/2011 4 American LegalNet, Inc. www.FormsWorkFlow.com