Order Number

Surname *

Title *

Firstname(s) *

Identity / Passport Number *

Occupation

Address to which we may send your letter *

Address 2

City/town

Province *

Phone Number 1

Postal Code *

Phone Number 2

E-mail *

Is there someone complaining with you?

Yes

How would you like to be contacted?

Email Phone Postal

In order for us to assist with your complaint, the total amount you are claiming may not exceed R800 000, this includes both capital and income. If this is the case, please take note of the following:

You will have to forego / abandon, in writing, the amount in excess of R800 000, or
The person you are complaining against will have to consent to this Office attending to your complaint.

If you do not agree to these terms, this Office unfortunately cannot assist with your complaint.

Please confirm your choice below:

I agree to forego the amount of my claim in excess of R800 000 *

Yes No

Which financial services provider, advisor or persons are you complaining about?:

This can be either:

The advisor / intermediary who advised you with regards to the product; or
The product provider for the financial product or investment that was recommended by the advisor / intermediary.

Name of the person or company

Their Address

Their Address line 2

Their Address City/Town

Province their

Contact Number

Is there any other person or business that you are complaining about?

yes

Please give us the names of the financial product / investment you are complaining about, and provide details of the product provider:

Please give us the names of the financial product / investment you are complaining about, and provide details of the product provider: *

In order for us to assist with your complaint, the total amount you are claiming may not exceed R800 000, this includes both capital and income. If this is the case, please take note of the following:

If you have already approached a Court for assistance, this Office cannot help with your complaint.
You have to approach the party you are aggrieved with first and provide them with a period of 6 weeks to resolve the matter before this Office can help with your complaint.
Please ensure that proof of this is attached to your complaint.

Tell us about the product or service you are complaining about

What type of financial product was sold to you? *

Investment Insurance Retirement Products Forex Products Medical Aid Other Financial Product, please specify

What type of financial product was sold to you? (SPECIFY)

The date when the financial product was sold to you: *

When did you first realise there was a problem? *

When did you first complain to the company / person? *

Have you approached the Courts for assistance?

Yes

Has the complaint been referred to any other Ombud?

Yes

If yes, which OMBUD

Their reference number

Please tell us about your complaint – what happened?

(Provide as much detail as possible, and feel free to expand in an annexure, if there is insufficient space. The documents you annex hereto will be deemed to form part of your complaint form)

When providing details of your complaint, please focus on the following:

Do you believe the advice and / or recommendation made was appropriate?
If not, provide details of why the advice or recommendation made was inappropriate.
What were the reasons for purchasing the financial product or making the investment, and the source of the funds used for the financial product or investment?
What was your understanding of the financial product or investment recommended?
What was disclosed to you with regards to the nature of the product and the risks involved?
Were you provided with a copy of the record of advice and the product information documentation?
Please provide this Office with copies of any and all documentation that will assist in the investigation of the complaint.

Your Complaint Summary

How have you been affected – financially or otherwise?

Upload relevant files

Please attach any documents relating to the complaint that you believe will support your complaint. Please note the following

Only PDF/Microsoft Word documents or images are allowed.
A maximum of 10MB is allowed, if you want to send files more than 10MB, please contact the office

Relevant files file

How would you like the financial services provider or persons being complained about to put things right for you?

Protection of Personal Information Act 4 of 2013

The FAIS Ombud is bound by the provisions of the Protection of Personal Information Act 4 of 2013 (POPI). All personal information collected will be appropriately handled and will only be used for the purposes which its collected.

We need your permission to go ahead

I would like FAIS Ombud to investigate my complaint

I understand that the Ombud or his/her staff may need to exchange information about my complaint with other organisations (for example to find out important information about my case)

Handles complaints in a different way to the courts

May publish examples of where things can go wrong, based on real cases but will always respect my privacy and keep my personal information confidential

I grant permission to the FAIS ombud to investigate my complaint

Declaration

I declare that the information furnished in this complaint form is true and correct in every aspect.