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SEC Complaint Form

SEC Complaint Form

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Published by Tim Bryant
Form to be used in filing a complaint with the Securities Exchange Commission (SEC).
Form to be used in filing a complaint with the Securities Exchange Commission (SEC).

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Categories:Types, Legal forms
Published by: Tim Bryant on Nov 09, 2012
Copyright:Attribution Non-commercial

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11/09/2012

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UNITED STATESSECURITIES AND EXCHANGE COMMISSIONWashington, DC 20549FORM TCRTIP, COMPLAINT OR REFERRAL
A. INFORMATION ABOUT YOU
COMPLAINANT 1:
1. Last NameFirstM.I.2. Street AddressApartment/ Unit #CityState/ ProvinceZIP/ Postal Code Country3. Telephone Alt. Phone E-mail Address4. OccupationPreferredmethod ofcommunication
COMPLAINANT 2:
1. Last Name
 
First M.I.2. Street AddressApartment/ Unit #CityState/ ProvinceZIP/ Postal Code Country3. Telephone Alt. Phone E-mail Address4. OccupationPreferredmethod ofcommunication
B. ATTORNEY’S INFORMATION (If Applicable - See Instructions)
1. Attorney’s Name2. Firm Name3. Street AddressCityState/ ProvinceZIP/ Postal Code Country4. Telephone Fax E-mail Address
 
C. TELL US ABOUT THE INDIVIDUAL OR ENTITY YOU HAVE A COMPLAINT AGAINST
INDIVIDUAL/ENTITY 1:
1. Type: Individual EntityIf an individual, specify profession:If an entity, specify type:2. Name3. Street AddressApartment/ Unit #CityState/ ProvinceZIP/ Postal Code Country4. Phone E-mail Address Internet Address
INDIVIDUAL/ENTITY 2:
1. Type: Individual EntityIf an individual, specify profession:If an entity, specify type: 2. Name3. Street AddressApartment/ Unit #CityState/ ProvinceZIP/ Postal Code Country4. Phone E-mail Address Internet Address
D. TELL US ABOUT YOUR COMPLAINT
1. Occurrence Date (mm/dd/yyyy): / / 2. Nature of complaint:3a. Has the complainant or counsel had any prior communication(s) with the SEC concerning this matter? YES NO3b. If the answer to 3a is “Yes,” name of SEC staff member with whom the complainant or counsel communicated4a. Has the complainant or counsel provided the information to any other agency or organization, or has any other agency or organization requestedthe information or related information from you?YES NO4b. If the answer to 4a is “Yes,” please provide details. Use additional sheets if necessary.4c. Name and contact information for point of contact at agency or organization, if known
 
5a. Does this complaint relate to an entity of which the complainant is or was an officer, director, counsel, employee, consultant or contractor?YES NO5b. If the answer to question 5a is “Yes,” has the complainant reported this violation to his or her supervisor, compliance office, whistleblower hotline,ombudsman, or any other available mechanism at the entity for reporting violations? YES NO5c. If the answer to question 5b is “Yes,” please provide details. Use additional sheets if necessary.5d. Date on which the complainant took the action(s) described in question 5b (mm/dd/yyyy): / 6a. Has the complainant taken any other action regarding your complaint? YES NO6b. If the answer to question 6a is “Yes,” please provide details. Use additional sheets if necessary.7a. Does your complaint relate to a residential mortgage-backed security? YES NO7b. Type of security or investment, if relevant7c. Name of issuer or security, if relevant 7d. Security/Ticker Symbol or CUSIP no.8. State in detail all facts pertinent to the alleged violation. Explain why the complainant believes the acts described constitute a violation of the federalsecurities laws. Use additional sheets if necessary.9. Describe all supporting materials in the complainant’s possession and the availability and location of any additional supporting materials not incomplainant’s possession. Use additional sheets, if necessary.

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