Dispute Resolution Form

Action to date

Applicant details

Dispute details

Name of the broker you have a dispute with

Please include as much information as you can, including the type of product involved, the dates the problem occurred, the name, address and telephone number (if you know these) of all
individuals and firms involved and a description of the problem (please attach a separate page if you need more space than provided)

Additional Comments

If you are seeking payment of a sum of money please provide any relevant calculations of your claim(s)

Supporting documents

Please attach copies of all documents you have that relate to your dispute. If your financial services provider has written to you about your dispute,
please ensure that you provide a copy of its response.

Please do not submit the following information:

• Personal ID documents: passports, driver’s licenses or other forms of personal identification

• Financial documents: bank statements, debit/credit card details

• Login information: usernames or passwords for trading, banking or other accounts

Please note: Financial Commission representatives will never ask you for your personal or financial details in the process of handing client disputes