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Section A. Personal Information
1. Full name
2. Date of birth
3. Address
4. Contact details
Phone
Email
5. What is your current occupation?
6. Was this your occupation at the time that you received and acted upon the financial advice? Yes No
If no, please provide details:
7. Do you have a spouse/partner? Yes No
If yes, what is your spouse/partner's current occupation?
If no, please go to Question 9.
8. Was this your spouse's occupation at the time that you received and acted upon the financial advice? Yes No
If no, please provide details:
9. Please provide your annual income and your spouse / partner’s annual income at the time of acting upon the financial advice.
a. Your annual income:
b. Your spouse / partner's annual income:
10. At the time you received and acted upon the financial advice, did you inform the financial advisor that you were either:
a. Planning to reture within the next 3 years of making that investment? Yes No
b. Had retired? Yes No
11. Are you currently retired? Yes No
If yes, when did you retire?
If no, when do you plan to retire? Please go on to Section B.
12. What was your occupation immediately prior to retirement?
Section B. Investment History
1. Do you have any previous experience with investments (i.e. property, shares, managed funds)? Yes No
If yes, please provide brief details of amounts and dates invested, advice sought or relied upon, and the result of these investments.
2. How did you come to know about the financial advisor?
If Referral or Other, please provide details:
3. If you came to know about the advisor through a friend/acquaintance, did that person have any connection with the advisor? Yes No
If yes, please provide details:
Section C. The Investment
1. When did you make the investment?
2. What was the amount invested?
3. What product(s) did you invest in?
4. Did you borrow any money to make the investment? Yes No
5. Did you borrow against the value of your property (ie house/unit)? Yes No
If no, please go on to Question 7.
6. Did you provide a mortgage to the bank? Yes No
If yes:
a. Which bank?
b. Please state the total amount borrowed against your property.
d. Are you the sole owner of the property against which the loans are secured? Yes No
If no, who are the other owners?
e. Prior to obtaining the mortgage, did you own your own property outright? Yes No
7. Are you the sole owner of the investment? Yes No
If no, who are the other owners?
Section D. Financial Advice
1. Who was your adviser(s)?
2. What are the adviser's contact details?
a. Firm name
b. Address
c. Phone
d. Email
3. When did you first receive advice from the adviser(s)?
4. When making your decision to invest, did you rely on advertising or documentation from the advisor? Yes No
If yes, please provide details.
5. Did you receive a statement of advice about the investment strategy? Yes No
6. Did your adviser explain the risks involved in relation to the investment? Yes No
7. What risks were you concerned about?
8. Did you inform your advisor of the risks that you were not prepared to take? Yes No
If yes, please provide details.
Section E. The Effects
1. Why do you believe you were negligently advised?
2. What financial losses have you suffered?
3. When were the losses incurred?
Section F. Steps Taken
1. Have you complained to the financial adviser? Yes No
If yes, please provide details or a copy of a written complaint, including any reponses you may have received.
2. Have you already discussed this matter with a legal adviser? Yes No
If yes, what advice did they provide?
3. Have you discussed this matter with any other professional advisers or government departments? Yes No
If yes, with whom and what advice did they provide?
Additional comments?
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