COMPLAINT QUESTIONNAIRE

INSTRUCTIONS:
  • Please complete this form, providing as much information and detail as possible.
  • Make copies of pertinent information, including front & back of all checks. At the completion of this form, You will be asked to mail copies of all documents in your possession to the Department. Do Not Send Originals!
  • Be specific when describing dates, times, persons, and what statements were made.
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    INFORMATION ABOUT THE COMPLAINANT:
    Name      DOB:  
     
    Address
    City ST Zip Phone
    E-Mail

    Place of Employment Trade/Occupation

    Address
    City ST Zip Phone

    Spouse/Partner's Name Trade/Occupation

     
    INFORMATION ABOUT THE SELLER:
    Business Name
    Primary Phone No. Secondary Phone No.
     
    Address
    City ST Zip

    Please provide as much of the following information as possible regarding the salesperson(s) you dealt with:

    Name Position Phone No. E-mail Address

    Did you know the salesperson or company prior to this investment?  Yes No If Yes, please explain:
     
    INFORMATION ABOUT THE OFFER:
    1. How was the offer to invest/purchase made?:
      • Telephone - Who Called & Date
      • Personal Visit - Who Visited & Date
      • Seminar or Group Sales Presentation - Location & Date
      • Newspaper/Magazine - Name & Date
      • Other: Explain Circumstances and include all dates)

    2. Where was the offer made?


    3. Who made the offer?

      What was their Position?


    4. Who else was present? (Name, Address, City, State, Zip Code, Telephone)


     
    INFORMATION ABOUT THE INVESTMENT:
    1. Describe the investment offered to you: (Example: Common Stock, Oil and Gas interests, etc.)


    2. Did you invest? Yes No
      When did you invest? Amount invested $

    3. How did you pay? (Cash, Check, Money Order, etc.)


    4. How much did you purchase? (Example: 1000 Shares; 5% Working Interest, etc.)

    5. Did you sign any type of contract? Yes No Date signed

    6. Where was the contract signed/money paid? (City/State)

    7. Do you know any other purchasers? Yes No
      Please list their Name, Address, City, State, Zip Code, Telephone





    8. What were you told about the investment?


    9. What untrue statements, if any, were made to you?


    10. What facts, if any, did the seller omit to tell you which would have changed your decision to invest?
     
    INFORMATION ABOUT THE COMPLAINT:
    1. Have you communicated with any other state or federal agency about this matter? Yes No
      a.
      b.
      c.

    2. Have you hired an attorney? Yes No
      If Yes, please identify: (Name/Address/Telephone)


    3. Describe your past and current investment experience: (Example: Savings Account, Mutual Funds, Oil & Gas interests, etc.)


    4. Are you willing to testify in an administrative hearing or court of law regarding this case?
      Yes No

    5. Are you willing to permit the Oklahoma Department of Securities to share information from this Questionnaire with other government departments and/or law enforcement agencies?
      Yes No

    6. Are you willing to permit the Oklahoma Department of Securities to share information from this Questionnaire to the firm or party your complaint is against in order to resolve the conflict?
      Yes No

    Click the Next button below to review your responses to this questionnaire.