Complaint Form - Indiana Securities Division Page 2
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1
2How did you pay?
☐ Cash
☐ Wire Transfer
☐ Other _____________
☐ Check
☐ IRA
☐ Yes
☐ No
Did you sign a written agreement/contract?
☐ No
☐ Yes
Have you hired an attorney?
If yes, what is the name of your attorney
☐ No
☐ Yes
Have you started a court action?
☐ Yes
☐ No
Have you filed a complaint with any other agency?
If yes, indicate what agency, filing date and action taken
Section 5: Additional Comments/Details
Please mail the completed form, along with copies (no originals) of any supporting documentation, to the Indiana
Securities Division:
Indiana Securities Division
302 W. Washington Street
Room E-111
Indianapolis, IN 46204
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