ANCSA CORPORATION COMPLAINT FORM This form can be completed on line, downloaded, signed, and submitted to the division by fax, or you can complete it and mail it in to the division. The jurisdiction of securities officials extends only to those matters that involve the solicitation of proxies and the requirement that certain individuals and ANCSA corporations have to report to the certain things to the division. These include proxy statements and solicitation materials, annual reports, consents or authorizations made available by any person to at least 30 Alaska shareholders of a corporation that has assets exceeding $1,000,000 and that have 500 or more members. We do not have jurisdiction over matters that have to do with the functioning of ANCSA corporations and matters involving failures or acts of management with which you disagree. You may have civil remedies, but the division lacks the ability to become involved. THIS FORM SHOULD NOT BE USED FOR COMPLAINTS ABOUT INVESTMENTS OR INVESTMENT COMPANIES. USE FORM 08-115A POSTED ON THE DIVISION WEBSITE FOR THOSE COMPLAINTS. Name, address, and telephone number of persons filing this complaint: Full name Address Home phone and best time to call Work phone and best time to call This complaint is about q an individual q a corporation. The name, address, and phone number are: (If more than one individual, please give the other names, addresses, and phone numbers that you have) Name of company and/or individuals Address Phone I believe this complaint is governed by the following statutes and regulations: _________________________________. 08-115B (10/99) q I don’t know what statute or regulation is involved. Page 1 American LegalNet, Inc. www.USCourtForms.com Label1 Please give a brief description of your complaint. We need to know the type of documents involved; the people involved or about whom the complaint is made. We’d also like to know if this is a first time complaint or is it something that came up in the past? Complaint description . . . Use additional sheets as necessary. 08-115B (10/99) Page 2 American LegalNet, Inc. www.USCourtForms.com Please make copies of any documents related to your complaint, and send the copies with this complaint. If you send any copies of checks, copy the front and the back. We will ask for you to send us the originals when we need them. If you send anything you want to have returned, please indicate what you want returned here: Do you know of anyone else who may have information related to this complaint? If so, please give us their names, addresses, and phone numbers, or as much information as you can: ***************************************************************************** Notice of application of the public records provisions of Alaska law. Under the public records provisions of Alaska law, AS 09.25.100 – 09-25.220, this complaint may become subject to public disclosure at some time after the investigation is ended. While this matter may be protected, your identity will be made known to the person or company you complain about. I certify that the information given above is true to the best of my knowledge. I understand that I can be held responsible if I make a false report. Signature (form must be signed above) Date FAX TO: (907) 465-1230 08-115B (10/99) Page 3 American LegalNet, Inc. www.USCourtForms.com