2. Name: ________________________________________________________________________________________
License Type (check one): Broker Salesperson License #: _________________
Who did he/she represent? __________________________________________________________________________
Address: _________________________________________________________________________________________
Phone No.: _______________________________________________________________________________________
Brokerage Name: __________________________________________________________________________________
Address: _________________________________________________________________________________________
Phone No.: _______________________________________________________________________________________
III. GENERAL INFORMATION ABOUT COMPLAINT
1. I have have not (check one) contacted the person(s) complained about and attempted to resolve this matter.
Who did you contact, and when?
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
2. Are you involved in a lawsuit about this matter? No Yes (If yes, please provide the following)
Case Title: ______________________________________________________ Case No.: ________________________
Court Name & Address: _____________________________________________________________________________
________________________________________________________________________________________________
Case Status: _____________________________________________________________________________________
3. Please attach a written narrative detailing the facts surrounding your complaint. Include copies of any documents,
emails, notes or other items relating to your complaint.
4. Provide the name(s) and contact information (if known) of any other person(s) who may have knowledge of this matter.
Please attach additional sheets as needed.
Name: ___________________________________________________________________________________________
Contact Info.: _____________________________________________________________________________________
Name: ___________________________________________________________________________________________
Contact Info.: _____________________________________________________________________________________
Name: ___________________________________________________________________________________________
Contact Info.: _____________________________________________________________________________________
IV. VERIFICATION OF COMPLAINT
I understand a copy of this complaint will be provided to anyone against whom I have complained. As the complainant, I
may be required to testify if this matter proceeds to a formal action.
I declare that the foregoing complaint is true and correct to the best of my knowledge.
________________________________________ _______________________________________
Complainant Signature Complainant Signature
COMMISSION ACTION ON COMPLAINT: You will receive written conrmation that your complaint has been received.
You may be asked to submit additional information or clarication, and you will be notied as to the nal disposition of
your complaint.
REE-004-12 Rev. 7/2020 Page 2 of 2
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