Claim for Order for payment of Financial Loss Section 148.2 – The Securities Act To: The Director The Manitoba Securities Commission 1130 – 405 Broadway Winnipeg, Manitoba R3C 3L6 CLAIMANT NAME: AGE: ADDRESS: CITY: PROVINCE: POSTAL CODE: WORK TELEPHONE: HOME TELEPHONE: FAX NUMBER: PERSON OR COMPANY WHO IS SUBJECT OF THE COMPLAINT: ADDRESS: CITY: PROVINCE: POSTAL CODE: WORK TELEPHONE: HOME TELEPHONE: FAX NUMBER: REGISTRATION CATEGORY OF SUBJECT (IF AVAILABLE): 1. What is the nature of the transaction involving the person or company who is the subject of the claim? Continue on an additional sheet of paper if necessary, but be concise. Provide loss information only for the amount of loss sustained as a result of the actions of the subject(s) of the claim. Itemize financial loss information. Attach documentation (canceled cheques, receipts, etc.) to support your figures.
2. Have you been reimbursed or will you be reimbursed (insurance or otherwise) for any portion of the loss listed above? YES NO If yes, explain and provide the name and address of the company that reimbursed your loss, the claim number for the loss, and how much reimbursement you received. 3. Have you or anyone on your behalf initiated court action against any party as a result of the matters described in this claim? YES NO (i) If yes, list case name, court file number, and court of jurisdiction. (ii) Do you intend to discontinue that court action claim and proceed with this claim? YES NO Acknowledgements of Claimant A: I am making this claim to The Director of The Manitoba Securities Commission to investigate whether a hearing should be commenced and to request an order from the Commission directing repayment of financial losses to me, pursuant to section 148.2 of The Securities Act. B: I understand that if the Director presents my claim at a hearing, there is no guarantee an order will issue in my favour following the hearing, nor is there any guarantee as to the amount of any order. C: I understand I lose the right to commence a court action to recover loss or damages arising from the subject matter of this claim once a hearing is commenced to consider my claim. D: I understand it is my responsibility to take whatever action is required to recover any amount directed to be paid to me if an order is issued following a commission hearing. E: I agree to cooperate with the Commission and its staff in the review of my claim and the commission investigation relating to the matters described in the claim. F: I understand that I have the right to hire a lawyer to act on my behalf. ____________________________ ____________________________________ WITNESS SIGNATURE OF CLAIMANT _____________________________ _____________________________ _____________________________ _____________________________ Print witness name & full address DATE STATEMENT COMPLETED:
For Commission Use Only Disposition of Hearing: Hearing and Decision by the Commission Settlement Agreement approved by the Commission Provincial Court Decision INVESTIGATION FILE NUMBER: Disposition of Claim Application received (Date: ) Director’s Approval (Date: ) Application abandoned (Date: ) Compensation Ordered Order filed in Queen’s Bench Payment received Other COMMISSION ORDER NUMBER:
You are being directed to the most recent version of the statute which may not be the version considered at the time of the judgment.