Department of Commerce & Insurance
Securities Division

500 James Robertson Parkway
Nashville, Tennessee 37243-0585
Phone: 615-741-5900 or 1-800-863-9117

Click here to find out what happens after your file your complaint.
Click here if you would like to download the complaint form instead of filling it out online.

Investor Complaint Form
(* denotes required field)
Enter Your Contact Information
*Full Name
*Home Phone
Work Phone
Cell Phone
Best Time To Contact You   (Choose One)
Preferred Contact Type   (Choose One)
Whom is your complaint against?
*Name of Person
*Name of Company
Company or Individual's Address
Zip Code
Company Phone
Company Website
Investment Product
Check all that apply:
Stock Bond Mutual Fund Promissory Note Oil & Gas Interest
Partnership Unit Options/Warrants Viaticals Other
If other, please list here:
Date Invested
Amount Invested
Number of Shares/Units
Price per Share/Unit
Investment Information
Did you receive a prospectus or sales literature before you invested? Yes No
Did you sign a contract to make the investment? Yes No
Please describe how you first learned about this investment opportunity
What specific information were you given that caused you to invest?
Were any statements of fact made before your investment that you now believe were false? Yes No
If so, please describe:
Have you learned any important facts since your investment that were not disclosed to you before your investment? Would these facts have changed your decision to invest, had you known those about them in advance? Yes No
If you answered yes to this question, please describe:
Did the person who sold you this investment ask you any questions about your financial condition, investment objectives, investment experience or risk tolerance? Yes No
How was the money you invested to be used?
What representations were made about the risk involved in the investment?
Complaint Detail
Describe your complaint in detail. Include the names of all persons who were involved in the sale of this investment, include the dates of all persons who were involved in the sale of this investment, include the dates of all conversations and meetings and describe the representations that were made and who made them. Attach copies of all documents related to the investment and the front and back sides of any checks used to purchase the investment. Please use additional paper if needed. (You would need to fill out and print this form and mail it in with your information).

Describe Complaint Here:
Final Step
Are you willing to be a witness if proceedings are initiated by the Securities Division?
Yes No

Please type in your name here. Please be advised that you agree that this digital signature represents your truthful acknowledgement and is a legal signature.

The information I have stated in this complaint is true and accurate to the best of my knowledge.
*Date (mm/dd/yyyy)