Secretary of State - Securities Division

Securities Division Complaint Form

The Indiana Securities Division can investigate possible violations of these statutes:

Indiana Securities Act (IC 23-2-1)
Indiana Loan Broker Act (IC 23-2-5)
Indiana Franchise Act (IC 23-2-2.5)
Indiana Takeover Offers Act (IC 23-2-3.1)
Indiana Collection Agency Act (IC 25-11)

Required field

I. Please select the subject matter that you feel best describes your complaint:

Securities/investments
Loan Broker
Franchise
Collection Agency
Takeover Offers

II. Please supply the following information about yourself:

Name:
Date of Birth:	(mm/dd/yyyy)
Address:
City:
State:	Zip:
Email Address:
Home Phone #:
Cell Phone:

III. Please supply the following information about the
person(s) and entities who you believe may have violated Indiana law:

Company Name:
Company Address:
City:
State:	Zip:
Phone number:
Website:

Individual(s) involved:
1.	Name:
	Address:
	City:
	State:	Zip:
	Phone number:

2.	Name:
	Address:
	City:
	State:	Zip:
	Phone number:

Note: Please include any additional names in Section VI "Other Information".

IV. Please describe what happened (include relevant dates, names & locations, etc.):

V. Do you have any records of the transaction?
Yes No

Please describe the documents you have:

VI. Please provide any other information here:

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Securities Division Complaint Form