ALABAMA SECURITIES COMMISSION COMPLAINT FORM STATE NAME AND ADDRESS OF FIRM OR PERSON COMPLAINT IS AGAINST: Name: Address: City: Phone Number: State: Zip Code: Email: STATE YOUR NAME AND ADDRESS: Name: Address: City: Home Phone Number: Email: State: Zip Code: Work Phone Number: TYPE OF COMPLAINT: Complaint against a Company or Firm Complaint against an Individual Other, Please Specify: Date of Transaction: Place of Transaction (Specify the States in which you and the salesman were located) Witnesses to the Transaction: State the type of investment involved (e.g. stock, note, limited partnership, etc. If you are not certain, describe on last page.) • If you invested in stock or bonds, what was the name of the issuing corporation? • If you invested in a note, who was the maker (Company or Individual) responsible for paying it? • If you invested in a partnership, what was the name of that partnership? • Other: Amount involved in transaction: Do you have and can you provide evidence of investment (front and back of checks; cashiers checks; YES NO money orders; etc.)? Did you sign any papers or documents? NO YES (If Yes, please attach copies of them.) American LegalNet, Inc. www.USCourtForms.com Complaint Form – Page 2 How did you first learn about this investment? Have you complained to the Company or Firm? NO YES (If yes, to whom?) What was the response? May we send a copy of your complaint to the firm or individual complained against? NO Does an attorney represent you in this matter? NO YES YES If YES, give Attorney's Name and Address: Name: Address: City: State: Zip Code: Did you begin any legal action against this company? NO YES (Explain) Are you willing to sign an affidavit or testify regarding your transaction with this Company? NO YES Specify other governmental or regulatory agencies contacted: May we send a copy of your complaint to another governmental agency or regulatory body for their review or investigation? NO YES Did you tape-record any of your conversations regarding the transaction(s)? NO YES Names, telephone numbers and/or addresses of any other known investors: American LegalNet, Inc. www.USCourtForms.com Complaint Form – Page 3 Please explain the entire circumstances surrounding your complaint in the space provided below. It is important to include all details about the transaction, no matter how unimportant you may think they are. Please be specific in referring to any names, dates or documents. Also, if any part of the transaction occurred outside of Alabama, please indicate that fact. Remember that it is better to include too much information, rather than too little information. Be sure to describe the type of investment and any instruments you received evidencing your investment. (If additional space is needed, attach more pages) The above is true and accurate to the best of my knowledge. Signature: Date: Return completed form to: Alabama Securities Commission Enforcement Division 770 Washington Ave Suite 570 Montgomery, AL 36130-4700 American LegalNet, Inc. www.USCourtForms.com