FINANCIAL SERVICES AUTHORITY

P.O. Box 991

Bois De Rose Avenue,
Mahe,
Seychelles

Complaint Form

1. Details of Complainant (to be completed in Block letters)

Full Name:

Home Address:

Business Address:

Mobile Number:

Other Telephone Number:

2. Details of the incident(s)

Full name, address and contact details of licensed entity/person (s) that you wish to lodge a complaint
against:

Date of Incident(s):

Time of Incident(s):

Please describe precisely the details of your complaint. Please write clearly and legibly. (Use
additional pages if necessary.)

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3. List of documents in support of your complaint enclosed with this form (Please enclose copies of
all relevant documents e.g. Correspondences, Agreements, Proof of payments/invoices etc.)

4. Declaration of complainant

By submitting this complaint form, I understand that I am making a request for an investigation of this matter by the
Financial Services Authority (FSA) and I hereby consent for the FSA to relay or seek necessary information from relevant
parties to enable the conduct of its enquiries relating to this complaint. I declare that all information provided on the pages
of this form and on any pages that I attach hereto are true and factual to the best of my knowledge. I further understand that
if I have knowingly, intentionally or willfully made false statements or intentional misrepresentations, I may be subjected to
the penalties for offence in accordance to section 43 (1) of the Financial Services Authority Act 2013.

Signature of the complainant Name/Company Name of the complainant Date

For Official Use

Date Received:
Case Number: Case Officer:

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