New Jersey Statewide Navigation Bar
NJ Department of Law & Public Safety Home
Division of Consumer Affairs
dca news Acting Bureau Chief, Amy G. Kopleton portrait... Acting Bureau Chief, Amy G. Kopleton portrait...
Division of Consumer Affairs A-Z List

On-line Complaint Form
(Formulario de Queja en Español)

Investor Information

Name:

Street Address:

City: State:   ZIP Code: Telephone Number

Daytime:

Evening:

FAX Number:

E-Mail Address:


Firm Information

Firm Name:

Street Address:

City: State:   ZIP Code:

Telephone Number (1) Telephone Number (2)

E-Mail Address:


The Bureau of Securities investigates complaints against individuals and firms selling securities or offering investment advice as well as companies issuing securities investments. The Bureau is empowered to bring administrative actions or civil law suits to enforce the registration and anti-fraud provisions of the New Jersey Uniform Securities Act. The Bureau may refer certain matters for criminal prosecution.

Please be advised that the Bureau does not have the specific authority to order restitution or the repayment of any monies which you may believe are due you.


1. Type of firm (if known):

If other, please specify:

2. Name and title of firm's agents or employees with whom you dealt:

Name:

Title: If known, type of professional designation used:
If other, please specify:


Name:

Title:

If known, type of professional designation used:


If other, please specify:

3. How was the initial solicitation made?

If other, please specify:

If the initial solicitation was made via the Internet, please specify URL/Web site/E-Mail address:

4. Type of investment product involved in your complaint:

If other, please specify:

5. Did you receive a prospectus when you purchased the investment?

Yes No

6. Have you contacted the firm about your complaint?

Yes No

If "YES," please provide the date contact was made, and the name and address of those you have contacted:

Name:

Street Address:

City: State:   ZIP Code: Date contact was made:


Name:

Street Address:

City: State:   ZIP Code:

Date contact was made:

7. Have you contacted another regulatory or law enforcement agency about your complaint?

Yes No

If "YES," please provide the following information:

Name of Agency:

Name of person contacted:

Street Address of Agency:

City: State:   ZIP Code: Date contact was made:


Name of Agency:

Name of person contacted:

Street Address of Agency:

City: State:   ZIP Code: Date contact was made:

8. Describe the facts of your complaint in the order in which they happened.

9. The amount of loss involved in the complaint $

10. The funds used for investment were originally drawn from:

If Other, please specify:

11. Investor's Age (optional)

Under 30 31-40 41-50

51-60 61-70 Over 70

12. Certification

I certify this complaint is true and correct to the best of my knowledge

Yes No


       

Please note that the answers on your complaint form will remain on the screen after you have submitted the form.
Please do not resubmit the form.



division: dca home | complaint forms | licensing boards | adoptions | proposals | minutes | consumer protection
departmental: lps home | contact us | news | about us | FAQs | library | employment | programs and units | services a-z
statewide: nj home | my new jersey | people | business | government | departments | search

Page last modified: New Jersey Home My New Jersey People Business Government Departments