FINRA ARBITRATION STATEMENT OF CLAIM

DISPUTE RESOLUTION SERVICES

CUSTOMER CODE OF ARBITRATION PROCEDURE

CASE INFORMATION

FINRA Case Number: _________________________ (Office Use Only)

Date Filed: _________________________

I. PARTIES TO THE DISPUTE

A. CLAIMANT INFORMATION

Full Legal Name: _________________________

Address:
_________________________
_________________________

City: _________________________ State: _______ ZIP: ___________

Telephone: _________________________ Email: _________________________

Social Security Number (Last 4 digits): XXX-XX-________

Claimant Type:
☐ Individual Investor
☐ Joint Account Holders
☐ Trust/Estate
☐ Corporation/Business Entity
☐ Other: _________________________

B. CLAIMANT'S REPRESENTATIVE (If Applicable)

Attorney/Representative Name: _________________________

Firm Name: _________________________

Bar Number: _________________________ State: _______

Address:
_________________________
_________________________

City: _________________________ State: _______ ZIP: ___________

Telephone: _________________________ Fax: _________________________

Email: _________________________

C. RESPONDENT(S) INFORMATION

Respondent 1 (Brokerage Firm)

Firm Name: _________________________

CRD Number: _________________________

Address:
_________________________
_________________________

City: _________________________ State: _______ ZIP: ___________

Respondent 2 (Individual Broker/Representative)

Full Name: _________________________

CRD Number: _________________________

Position/Title: _________________________

Associated Firm: _________________________

Additional Respondents (If Applicable)

Name: _________________________ CRD Number: _________________________

Name: _________________________ CRD Number: _________________________

II. ACCOUNT INFORMATION

Account Number(s): _________________________

Account Type:
☐ Individual
☐ Joint Tenants with Rights of Survivorship
☐ Tenants in Common
☐ IRA/Retirement Account
☐ Trust Account
☐ Margin Account
☐ Options Account
☐ Corporate Account
☐ Other: _________________________

Date Account Opened: _________________________

Date Account Closed (if applicable): _________________________

Approximate Account Value at Opening: $______________

Approximate Account Value at Closing/Currently: $______________

III. CLAIM AMOUNT AND HEARING LOCATION

A. Claim Amount

Total Damages Claimed: $______________

Breakdown of Damages:

B. Claim Size Category

☐ Simplified Arbitration (claims of $50,000 or less)
☐ Standard Arbitration ($50,001 - $100,000)
☐ Large/Complex Case (over $100,000)

C. Requested Hearing Location

Preferred City: _________________________ State: _______

Alternative Location: _________________________ State: _______

IV. STATEMENT OF CLAIM

A. SUMMARY OF DISPUTE

[Provide a clear, concise summary of the dispute in 2-3 paragraphs]

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

B. FACTUAL BACKGROUND

1. Investment Profile of Claimant

Age at Time of Account Opening: _______

Occupation: _________________________

Annual Income (at time of investment): $______________

Net Worth (excluding primary residence): $______________

Investment Experience:
☐ None/Limited
☐ Moderate
☐ Extensive

Stated Investment Objectives:
☐ Capital Preservation
☐ Income
☐ Growth
☐ Speculation
☐ Other: _________________________

Risk Tolerance:
☐ Conservative
☐ Moderate
☐ Aggressive

Investment Time Horizon: _______ years

Liquidity Needs:
☐ Immediate access needed
☐ Some liquidity needed
☐ Long-term investment acceptable

2. Chronology of Events

[Provide a detailed, chronological account of relevant events]

Date: _____________ Event: _________________________________________________
_________________________________________________________________________________

Date: _____________ Event: _________________________________________________
_________________________________________________________________________________

Date: _____________ Event: _________________________________________________
_________________________________________________________________________________

Date: _____________ Event: _________________________________________________
_________________________________________________________________________________

Date: _____________ Event: _________________________________________________
_________________________________________________________________________________

[Continue as necessary]

3. Securities and Transactions at Issue

C. CAUSES OF ACTION

[Check all that apply and provide supporting facts]

1. ☐ Breach of Fiduciary Duty

Respondent(s) owed Claimant a fiduciary duty and breached that duty by:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

2. ☐ Negligence

Respondent(s) failed to exercise the degree of care that a reasonably prudent securities professional would have exercised under similar circumstances by:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

3. ☐ Unsuitability (FINRA Rule 2111)

The recommended transactions and/or investment strategy were unsuitable for Claimant based on:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

4. ☐ Churning/Excessive Trading

Respondent(s) engaged in excessive trading in Claimant's account for the purpose of generating commissions, as evidenced by:

• Annualized Turnover Ratio: _______
• Cost-to-Equity Ratio: _______%
  _________________________________________________________________________________

5. ☐ Misrepresentation/Omission of Material Facts

Respondent(s) made material misrepresentations and/or omitted material facts, including:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

6. ☐ Fraud (Securities Exchange Act Section 10(b) and Rule 10b-5)

Respondent(s) engaged in fraudulent conduct by:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

7. ☐ Unauthorized Trading

Respondent(s) executed trades without Claimant's authorization on the following dates:
_________________________________________________________________________________
_________________________________________________________________________________

8. ☐ Failure to Supervise

The firm Respondent failed to adequately supervise its registered representative(s) by:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

9. ☐ Breach of Contract

Respondent(s) breached the account agreement and/or other contractual obligations by:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

10. ☐ Other Claims

Specify: _________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________

V. RELIEF REQUESTED

Claimant respectfully requests that the Arbitration Panel award the following relief:

A. Compensatory Damages

☐ Actual/Direct Damages: $______________
☐ Consequential Damages: $______________
☐ Rescission and/or Rescissionary Damages: $______________

B. Interest

☐ Pre-judgment Interest at the rate of ______% from _____________ to the date of award
☐ Post-judgment Interest at the statutory rate

C. Punitive Damages

☐ Punitive Damages in an amount to be determined by the Panel (where permitted by law)

D. Costs and Fees

☐ Attorneys' Fees (where permitted by contract or law)
☐ Expert Witness Fees
☐ Filing Fees
☐ Forum Fees
☐ Other Costs: _________________________

E. Other Relief

☐ Expungement of Claimant's CRD Record (if applicable)
☐ Other Equitable Relief: _________________________
☐ Any other relief the Panel deems just and appropriate

VI. SUPPORTING DOCUMENTS

The following documents are attached in support of this Statement of Claim:

☐ Account Opening Documents/New Account Form
☐ Account Agreements
☐ Monthly Account Statements (specify period: _____________ to _____________)
☐ Trade Confirmations
☐ Correspondence with Respondent(s)
☐ Written Complaints to Firm
☐ Firm's Response(s) to Complaints
☐ Expert Reports/Analysis
☐ Damage Calculations
☐ Other: _________________________

VII. CERTIFICATIONS AND SIGNATURES

A. Certification of Eligibility

Claimant certifies that:

1. ☐ This claim is being filed within the applicable statute of limitations
2. ☐ The dispute arises out of the business activities of a member or associated person
3. ☐ Claimant has read and agrees to be bound by the FINRA Code of Arbitration Procedure

B. Certification of Accuracy

I certify under penalty of perjury that the information provided in this Statement of Claim is true and correct to the best of my knowledge, information, and belief.

Claimant Signature: _________________________ Date: _____________

Print Name: _________________________

Attorney Signature (if applicable): _________________________ Date: _____________

Print Name: _________________________

VIII. SUBMISSION AGREEMENT

The undersigned parties hereby submit the present matter in controversy to arbitration in accordance with the FINRA Code of Arbitration Procedure for Customer Disputes.

The undersigned parties agree to abide by and perform any award(s) rendered pursuant to this Submission Agreement. The parties further agree that a judgment and any interest due thereon may be entered upon such award(s) and, for these purposes, the parties hereby voluntarily consent to submit to the jurisdiction of any court of competent jurisdiction which may properly enter such judgment.

Claimant Signature: _________________________ Date: _____________

Print Name: _________________________

STATE-SPECIFIC CONSIDERATIONS

California

• California Corporate Securities Law of 1968 may provide additional remedies
• California Civil Code Section 1709 (fraud) and 1710 (deceit) may apply
• California statute of limitations: generally 4 years for breach of fiduciary duty, 3 years for fraud
• File with California Department of Financial Protection and Innovation if state law claims included

Texas

• Texas Securities Act provides for civil liability under Section 33
• Texas Deceptive Trade Practices Act may provide additional remedies
• Texas statute of limitations: 5 years for fraud, 4 years for breach of fiduciary duty
• Consider concurrent filing with Texas State Securities Board

Florida

• Florida Securities and Investor Protection Act (Chapter 517) may provide additional remedies
• Florida statute of limitations: 5 years for fraud, 4 years for breach of fiduciary duty
• Florida Office of Financial Regulation should be notified of significant violations

New York

• New York Martin Act provides broad anti-fraud powers (primarily for Attorney General)
• New York General Business Law Article 23-A applies to certain securities
• New York statute of limitations: 6 years for fraud, 6 years for breach of fiduciary duty
• Consider CPLR 213(8) for fraud claims (6 years from occurrence or 2 years from discovery)

FILING INSTRUCTIONS

1. Online Filing: File through FINRA's DR Portal at https://www.finra.org/arbitration-mediation/file-claim
2. Mail Filing (Pro Se Only): FINRA Dispute Resolution Services, Brookfield Place, 200 Liberty Street, New York, NY 10281
3. Filing Fee: Based on claim amount per FINRA Rule 12900 fee schedule
4. Service: Serve Respondent(s) with copy of Statement of Claim per FINRA rules
5. Response Deadline: Respondent has 45 calendar days to file an Answer

This template is provided for informational purposes only and does not constitute legal advice. FINRA arbitration procedures are governed by specific rules that change periodically. Consult a qualified securities attorney and review current FINRA rules before filing.