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.
  •  
    INFORMATION ABOUT THE COMPLAINANT:
    Title   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 salespersons 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?  
      How much did you invest?  
     
    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  
      Please list the agency and the person you spoke with.
     
    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 Next below to review your responses to this questionnaire. You will have the opportunity to make changes.