SECURITIES AND BUSINESS REGULATION 2 Martin Luther King, Jr. Drive, S.E. Ste 802, West Tower Atlanta, Georgia 30334 (404) 656-3920 KAREN HANDEL Secretary of State ROBERT D. TERRY http://www.sos.state.ga.us/securities/ DIVISION DIRECTOR PUBLIC COMPLAINT FORM Your Information Your Name: Address: Telephone: ( ) Your Signature: Date: Please Mark Area(s) of Complaint Securities Securities Broker/Dealer Securities Salesperson Securities Investment Advisor Securities Investment Advisor Representative Cemeteries/Preneed Funeral Home/ Preneed Dealer Cemeteries Merchandise Dealer Cemeteries Preneed Sales Agent Charitable Organization Charities Paid Solicitor Charities Solicitor Agent Information Relating to Business or Individual Involved Name Registration Number Telephone Address Address City State Zip Code Names of other businesses or individuals involved (explain below): Information Relating to Complaint Date the business or individual contacted you? How were you contacted (phone, mail, in person, etc.)? Date of investment/purchase/donation? What did you invest in, purchase, or donate (explain)? Did you sign any documents (if so, please explain)? List all pertinent witnesses and their phone numbers? Have you brought any legal action (if so, what)? Please attach a detailed explanation of your complaint. Include names, addresses, dates, amount, etc. Send copies of all relevant materials pertaining to your complaint to the address above, ATTN: Complaint Coordinator This Complaint Form may be sent to a professional trade organization or other similar organization related to the business identified in the complaint in an effort to resolve this dispute. If for any reason you do not want a copy of this complaint sent to such an organization, please put an 'X' HERE: _____ I do not want this complaint sent to a professional trade organization. Public Complaint Form Rev. 8/2006 American LegalNet, Inc. www.FormsWorkflow.com