THIS FORM IS ONLY FOR THOSE FILING A NOTICE PURSUANT TO MO. REV. STAT. §§ 409.600 – 409.630. PLEASE MAKE ALL OTHER COMPLAINTS AT THE FOLLOWING LINK: Complaint Form

Notification Pursuant to the Senior Savings Protection Act

(Mo. Rev. Stat. 409.600, et seq.)

Directions

Please complete the following questions with as much detail as possible. This allows our staff to gather and analyze the most pertinent information in assessing this notification and a possible enforcement action.

Filer/Reporter Information

* Your Name:

Title:

Employer/Affiliated Brokerage Firm:

Address:

City:

State:

Zip Code:

* Telephone:

E-mail address:

Type of Notice

* Is this a notification that financial exploitation of a qualified adult (i.e. an adult aged 18-59 with a disability or an adult age 60 and above) has occurred, has been attempted, or is being attempted?

Yes

* Who will you notify or have you notified about the suspected financial exploitation of the qualified adult? Please enter the name, titles, relationship to the victim, and contact information of each individual and/or agency in the space provided below: (8000 characters allowed)

8000 characters remaining on input limit

Have you refused a request for a disbursement or will you refuse a request for a disbursement? If so, provide the date upon which that refusal occurred or will occur.

Qualified Individual Refusing Request for a Disbursement

Name:

Title:

Employer/Affiliated Firm:

Address:

City:

State:

Zip Code:

Telephone:

E-mail Address:

Broker-Dealer Agent Information

Name of Qualified Adult's Agent:

Address of Agent:

City:

State:

Zip Code:

Telephone:

E-mail Address:

Supervisor's Name:

Qualified Adult (Suspected Victim)

* Name:

Date Of Birth:

Marital Status:

Gender:

Address:

City:

State:

Zip Code:

Home Telephone:

Cell Telephone:

Email Address:

Other:

Please provide any information - including contact information - regarding all parties authorized to transact business on the account, immediate family members, person(s) with a power-of-attorney, guardians, conservators, co-trustees, successor trustees, and/or those holding a similar legal status with regard to the potential victim : (8000 characters allowed)

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Person Suspected to have Engaged in the Financial Exploitation

* Name:

Date Of Birth:

Address:

City:

State:

Zip Code:

Telephone:

Email Address:

Relationship to Victim:

Refusal of the Requested Disbursement (Financial Transaction)

Who requested the disbursement (financial transaction)?

Amount of funds requested:

Where were the funds to be sent?

In connection with the requested disbursement, was or would there be any sale of securities from the account of the qualified adult or an account on which a qualified adult is a beneficial owner?

Please provide a detailed explanation of why the qualified individual believes that the requested disbursement will result in financial exploitation. Provide the names and contact information of all relevant parties not previously indicated : (8000 characters allowed)

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Other Please provide any other additional information you feel is pertinent to this notification : (8000 characters allowed)

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Please be advised that the Missouri Securities Division, and the Department of Health and Senior Services are prohibited by law from giving you legal advice, legal opinions, or acting as your attorney. Therefore, you may wish to consult with a private attorney to discuss your legal rights and remedies.

If you have any questions about this form, please call the Missouri Securities Division investor hotline at 1-800-721-7996 and/or the Department of Health and Senior Services Adult Abuse and Neglect Hotline at 1-800-392-0210.

Please mail all correspondence to:
Office of the Secretary of State
Securities Division
PO Box 1276
600 W. Main St.
Jefferson City, MO 65102
Please e-mail [email protected] for co-investigation as necessary.

Digital Signature

*Denotes required fields. Form will be rejected if the information is not complete.

*I agree that the information provided is accurate to the best of my knowledge and wish to provide a Digital Signature to my complaint. Yes No