Illinois Secretary of State Securities Department Jefferson Terrace, Ste. 300 A, 300 W. Jefferson St.Business Broker Springfield, IL 62702 217-782-2256Client Statement 69 W. Washington St., Ste. 1220 Chicago, IL 60602 312-793-3384 800-628-7937 By completing this statement you will be assisting the Illinois Securities Department with the inquiry of a Business Broker. The information received will enable the Securities Department to conduct a more accurate inquiry. CLIENT INFORMATION: Name: Age: Address: City: State: ZIP: Home Telephone Number: Work Telephone Number: Please indicate the most convenient day to be contacted: ? Monday ? Tuesday ? Wednesday ? Thursday ? Friday Please indicate the most convenient time and place to be contacted: ? Work (indicate time): ? Home (indicate time): Please indicate how you signed a contract with the Business Broker: ? as an individual ? in the name of a company ? Partnership ? Corporation ? Limited Liability Company ? Other If an individual, do you have a net worth of more than $1 million or income of more than $200,000 including your spouse? ? Yes ? No If a company, does it have an asset value of more than $1 million or gross revenues of more than $200,00, or is it 90 percent owned by personswith assets of more than $1 million or income or gross revenues of more than $200,000? ? Yes ? No INQUIRY REFERENCE TO: Name of Business Broker: Address: City: State: ZIP: Telephone Number: E-mail/Internet Address: Printed by authority of the State of Illinois. May 2005 100 SEC 323 American LegalNet, Inc. www.USCourtForms.com>>>> 2Name, Title/Position (if known), Address, Telephone Number and E-mail/Internet address (if known) of person you dealt with: TRANSACTION INFORMATION: Describe how you contacted or were contacted by the Business Broker: Did you sign a contract for the Business Brokers services? ? Yes (indicate date you signed the contract): ? No Did you have the contract reviewed by an attorney before signing? ? Yes (indicate name and address of attorney): ? No Did the Business Broker provide you a written description of the services to be performed, the circumstances under which the BusinessBroker would be entitled to keep or receive a fee, and the business history of the business broker? ? Yes (indicate when this was provided to you): ? No MISCELLANEOUS: Have you filed an inquiry or complaint with the Business Broker, the Better Business Bureau or any other person or governmental agency? ? Yes ? No If yes, indicate Name, Address and Telephone Number of Person or Agency, and Date: What, if any, action has been taken? Have you obtained private legal counsel? ? Yes ? No If yes, indicate Name, Business Address and Telephone Number of Attorney: ATTACH COPIES OF ANY DOCUMENTS REGARDING THIS MATTER. (Include the front and back of all cancelled checks, or other evidences ofpayment of the Business Brokers fee.) Are you willing to be interviewed by a Securities Department investigator? ? Yes ? No Are you willing to testify if formal proceedings are commenced? ? Yes ? No DESCRIBE IN DETAIL ANY OTHER INFORMATION THAT MAY HELP THE SECURITIES DEPARTMENT UNDERSTAND THE AGREEMENT AND ANY DISCUSSION BETWEEN YOU AND THE BUSINESS BROKER. IF MORE SPACE IS NEEDED, PLEASE ATTACH ADDITIONAL SHEETS: Signature of Borrower Date Printed by authority of the State of Illinois. May 2005 100 SEC 323 American LegalNet, Inc. www.USCourtForms.com