Nevada Secretary of State, Securities Division
COMPLAINT FORM
This form is to be completed online before printing. If you are unable to do
so, please contact the Securities Division at (702) 486-2440 for guidance.
Instructions:
1) Complete and print this form
2) Attach/Include necessary information (see section 5)
3) Mail to: Contact Information:
NEVADA SECRETARY OF STATE,
Telephone: 702-486-2440
SECURITIES DIVISION
Fax: 702-486-2452
2250 Las Vegas Blvd. North, Suite 400 Email: [email protected]
North Las Vegas, NV 89030 Website: www.nvsos.gov
The Division may begin an investigation upon receipt of this form. All information provided is
deemed confidential and will not be available for public inspection except otherwise required by
law.
Date of Birth:
SECTION 1: Personal Information
Last Name First Name Middle Name
Street City State Zip
- - - -
(Area Code) Home Phone (Area Code) Work Phone (Extension)
- -
(Area Code) Cell Phone Email Address
Level of Education Completed: Marital Status:
High School Married
Bachelor of Science/Arts Single
Masters/MBA Widowed
Doctorate PhD Divorced
Other Other
Nevada Secretary of State Securities Division Complaint Form Page 1 of
5 Revised: 7-26-18
Past Investment Experience (stock, bonds, business owner, etc.):
SECTION 2: Information About Investment Offering
(please provide name(s) of all persons involved)
General Information
Name of Sales Person/Individual:
Firm/Company:
Doing Business As:
Street Address:
City:
State:
Zip Code:
Telephone #:
List of all Web sites and Email
Address:
Name of Sales Person/Individual:
Firm/Company:
Doing Business As:
Street Address:
City:
State:
Zip Code:
Telephone #:
List of all Web sites and Email
Address:
Manner of Offering Please check all that apply
Telephone Solicitation Radio
Personal Visit Letter/Mail
Newspaper Advertising Pamphlet
Television Group Sales Presentation
Internet Other (attach statement/example)
Nevada Secretary of State Securities Division Complaint Form Page 2 of 5
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Describe and List the investment(s) related to this complaint; please include purchase and/or sale dates,
dollar amounts, method of payment, etc.
Where was the salesperson physically located at the time of the sale? If the sale was made by
telephone, from what location was the salesperson calling you? (Address, City, State)
Have you made a report or filed a complaint with any other regulatory entity or agency, or with an
attorney? If so, please provide the details below.
SECTION 3: Bank Account Information
Do you know the name of the bank or account in which your money was deposited? If so, please provide
details.
If the investment was cash, did you receive a receipt?
YES NO
Nevada Secretary of State Securities Division Complaint Form Page 3 of 5
Revised: 1-5-15
SECTION 4: Complaint Details Please summarize your complaint using these guidelines:
• Tell us WHAT happened. Begin with how you first learned of the investment. Be specific as to what
was said and by whom.
• Tell us WHO was present during these conversations and meetings; please include the names,
addresses and telephone numbers of any witnesses.
• Tell us WHEN and WHERE conversations/meeting took place.
• Tell us WHEN and WHERE the money and/or agreements changed hands.
• Tell us HOW you know that false representations were made or HOW you know your money was
misused; please offer all facts/evidence that you have available in support of your complaint.
Please keep dates and events in sequence.
Nevada Secretary of State Securities Division Complaint Form Page 4 of 5
Revised: 1-5-15
SECTION 5: Attachments
Attach photocopies of all documents such as statements, confirmations, contracts, agreements,
certificates, notes, trust deeds, correspondence, legible copies of the front and back of checks,
prospectus, advertising, etc. Documentary evidence is especially important. Please do not send
originals as we cannot be responsible for their safekeeping.
Are you willing to testify in a court of Law regarding this case?
YES NO
NOTICE:
It is a violation of Nevada law to willfully make a materially false,
fictitious or fraudulent statement or representation in an investigation.
Violations may subject a person to civil or criminal penalties.
Please make sure your complaint is:
- completed electronically and printed
- signed with an original signature
- complete and includes all photocopied attachments
In filing this complaint, you are stating the information you are providing is true and
correct to the best of your knowledge and that the information may be used by the
Division to further investigate your complaint.
X
Signature of Complainant Date
IF THIS REPORT WAS PREPARED BY SOMEONE OTHER THAN COMPLAINANT, PLEASE
INDICATE WHO PREPARED THIS REPORT
X
Signature of Person Completing Report Date
PRINT Nevada Secretary of State Securities Division Complaint Form Page 5 of 5
Reset
Revised: 1-5-15
