STATE OF HAWAII Securities Enforcement Branch Department of Commerce & Consumer Affairs 335 Merchant Street, Suite 205, Honolulu, Hawaii 96813 Post Office Box 40, Honolulu, Hawaii 96810 COMPLAINT FORM Please type or print clearly. Attach separate sheet if more space required. Case Number: COMPLAINANT Mr. Mrs. Ms. ( ( ( ) ) ) Complainant's Name : Date of Birth: Driver's License or State Identification Number: Home Address : Mailing Address : Home Telephone : Issuing State: Work Telephone: Name(s) of company and/or individual your complaint is against : RESPONDENTS FEIN : Address : Telephone : Witness Name(s) : Address : Telephone : WITNESSES Witness Name(s) : Address : Telephone : Witness Name(s) : Address : Telephone : American LegalNet, Inc. www.FormsWorkFlow.com State of Hawaii Securities Enforcement Branch Complaint Form Page Two COMPLAINT SUMMARY. Please type or print in dark ink a complete and detailed chronological statement of your complaint. Include copies of all documents, such as contracts, correspondence, receipts, statements, and photographs. If you need additional space, continue on a separate sheet of paper and attach to this form. DATE/TIME EVENT American LegalNet, Inc. www.FormsWorkFlow.com State of Hawaii Securities Enforcement Branch Complaint Form Page Three 1. Did you sign any contract/agreement? If yes, please include a copy of the contract/agreement. Who negotiated the contract for the respondents? If the contract/agreement was not in writing, explain your understanding of the terms of your contract/agreement. 2. Did you and/or the respondent(s) modify or amend the contractual terms? If yes, explain the modification or amendment. 3. Were any guarantees and/or promises made? If yes, please include copies of any guarantees or written promises. If not in writing, explain your understanding of the terms of the verbal guarantees and/or promises. 4. If contract was made because of an advertisement, please provide a copy of the advertisement. If not available, then provide the date of the advertisement and where it was located such as a sign, newspaper, radio, television, magazine, leaflet, etc. 5. Have you attempted to settle your complaint with the Respondent? If yes, provide detailed facts on your attempt. Include date complained and name and title of person to whom you complained. American LegalNet, Inc. www.FormsWorkFlow.com State of Hawaii Securities Enforcement Branch Complaint Form Page Four 6. Have you attempted to settle your complaint with another agency or with the Courts? If yes, what agency or Court (provide the name and address of person contacted)? 7. What would you consider to be a fair resolution of your complaint and why? 8. Please attach relevant documentation to support your complaint. If documents are not attached, explain why you are not providing documents to support your complaint: CERTIFICATION OF COMPLAINT This complaint will not be processed unless this form is complete, legible and signed. I hereby certify that all statements in this complaint are true and correct to the best of my knowledge, and I agree to testify. Complainant's Signature Date NOTE: This material can be made available for individuals with special needs. Please call the division secretary, Business Registration Division, Department of Commerce and Consumer Affairs (DCCA) at 586-2744 to submit your request. Revised 10/08 American LegalNet, Inc. www.FormsWorkFlow.com