Standard Complaint

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Please, correct the following errors:

First Name:*

Last Name:*

Title:

Address:*

City:*

State:*

Zip Code:*

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Telephone Number:*

Email Address:*

Complaint

Exchange or Facility Involved:*

Briefly provide details of your complaint (you may also attach documents):*

Names of Wrongdoers:

Names of Victims:

Date(s) when the event(s) occurred:

Names of witnesses:

Has this matter been previously reported ?

Yes No

If yes, please provide the dates and who you reported it to:

Have you contacted the IG about this issue before?

Yes No

If yes, please provide date contact was made and to whom:

What do you want the IG to do for you?

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Consent to Disclose

Your Contact Information

First Name:*

Last Name:*

Title:

Address:*

City:*

State:*

Zip Code:*

Please contact me by:*

Telephone Number:*

Email Address:*

Complaint

Exchange or Facility Involved:*

Briefly provide details of your complaint (you may also attach documents):*

Names of Wrongdoers:

Names of Victims:

Date(s) when the event(s) occurred:

Names of witnesses:

Has this matter been previously reported ?

If yes, please provide the dates and who you reported it to:

Have you contacted the IG about this issue before?

If yes, please provide date contact was made and to whom:

What do you want the IG to do for you?