DIVISION OF SECURITIES STATE OF COLORADO Rev: 6/2012 COMPLAINT FORM PROCEDURE FOR FILING A COMPLAINT (Please read and detach) This office is responsible for looking into investment opportunities to make sure they are in compliance with Colorado securities laws. If you feel you have been a victim of, or have information concerning, an unlawful investment program please complete the attached complaint form and mail it to us. SOME TIPS ON PREPARING A WRITTEN COMPLAINT 1. If we can’t clearly understand your complaint or inquiry it will be more difficult for us to help you. Please take a minute to ORGANIZE your information so that the details are clearly and completely stated. 2. Before you begin it might help you to make a list of the things you want to say. 3. Try to present the events in the order in which they occurred using dates whenever possible. 4. Please type or write legibly. 5. If you can, please enclose legible copies of documents such as contracts, prospectuses, agreements, cancelled checks (front and back), advertisements, letters or other documents that may be central to your complaint. If your copies are numerous please send only the most important ones. 6. Please COMPLETE Pages 2 & 3 of the complaint form and return it to our office. MAIL OR DELIVER your complaint to: The Colorado Division of Securities 1560 Broadway Street, Suite 900 Denver, CO 80202 Upon receipt a member of our staff will begin a review of your complaint as soon as possible depending on the circumstances of the complaint and resources available. However, please realize that although you may feel that you have been “ripped off” this does not necessarily mean that the business has engaged in unlawful activity or that it is within our jurisdiction or authority to pursue. Once we have received your complaint a member of our staff will be in contact with you as soon as possible. We are prohibited by law from giving you legal advice, legal opinions or acting as your private attorney. Therefore, you may wish to contact a private attorney to discuss your legal rights and remedies. If your complaint involves a firm that is registered with the Securities and Exchange Commission and/or is a member of the Financial Industry Regulatory Authority (FINRA) you may wish to contact those agencies directly. If you reside in a state other than Colorado you may also wish to contact your own state securities agency. -1American LegalNet, Inc. www.FormsWorkFlow.com DIVISION OF SECURITIES STATE OF COLORADO COMPLAINT FORM ______________________________________________________________________________________ STATE YOUR NAME, ADDRESS NAME & ADDRESS OF THE FIRM and/or AND DATE OF BIRTH: PERSON YOU ARE COMPLAINING OR INQUIRING ABOUT: DATE OF BIRTH: Phone: (Res.): Phone: (Bus.): ______________________________________________________________________________________ 1. Date you were first contacted: 2. Date of investment (if applicable): 3. What did you buy or what were you solicited to buy? (i.e., stocks, debentures, limited partnerships etc.) 4. Amount invested: 5. Did you sign any documents? YES NO (Attach copies of each if possible) 6. Name of person who sold the investment to you: 7. How many other investors are involved in this investment? 8. Was the product or service advertised? YES NO If YES, state how advertised and date 9. Have you complained to the firm? YES NO If YES, to whom? What was their response? 10. When did you last hear from the firm? The salesperson? 11. What other agencies have you contacted to file a complaint? 12. Have you brought any legal action involving this investment? YES NO (PLEASE PROVIDE AN EXPLANATION OF YOUR COMPLAINT ON THE NEXT PAGE) -2American LegalNet, Inc. www.FormsWorkFlow.com Please provide a detailed explanation of your complaint below. Include names, addresses, dates, amounts, etc. (You may attach additional pages if necessary): -3American LegalNet, Inc. www.FormsWorkFlow.com