Indiana Secretary of State Securities Division Complaint Form Online version available at: http://www.in.gov/sos/securities/sec_complaint.html The Indiana Securities Division can investigate possible violations of these statutes: Indiana Securities Act (IC 23-2-1) Indiana Loan Broker Act (IC 23-2-5) Indiana Franchise Act (IC 23-2-2.5) Indiana Collection Agency Act (IC 25-11) Indiana Takeover Offers Act (IC 23-2-3.1) I. Please select the subject matter that you feel best describes your complaint: Securities/investments Loan Broker Collection Agency Franchise Takeover Offers II. Please supply the following information about yourself: Name: __________________________________________________________________ Date of Birth: ____/____/____ Address: __________________________________________________________ Street City, State Zip Code Email Address______________________________________________________ Home Phone #: (____) ____-______ Cell Phone #: (____) ____-______ III. Please supply the following information about the person(s) and entities who you believe may have violated Indiana law: Company name: ______________________________________________________________________ Address:______________________________________________________________ Phone number: ________________________________________________________ Website: ______________________________________________________________ Individual(s) involved: 1) ____________________________________________________________________ Address:______________________________________________________________ Phone number:_________________________________________________________ 2) ____________________________________________________________________ Address:______________________________________________________________ Phone number:_________________________________________________________ Note: Please include any additional names in Section VI “Other Information”. 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Please describe what happened (include relevant dates, names & locations, etc.): ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com V. Do you have any records of the transaction? Yes │ No Please describe the documents you have: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ VI. Please provide any other information here: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Please mail the completed form, along with copies (no originals) of any supporting documentation, to the Indiana Securities Division: Indiana Securities Division 302 W. Washington Street Room E-111 Indianapolis, IN 46204 Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com