IOWA SECURITIES BUREAU 340 E. Maple St. Des Moines, IA 50319 (515) 281-4441 Fax (515) 281-6467 QUESTIONNAIRE INSTRUCTIONS: 1. Type or print legibly. 2. Make copies of pertinent information. Do Not Send Originals! Please copy front and back of all checks. 3. Be specific when describing dates, times, persons, and what statements were made. 4. If you need more space for an answer, provide the information on additional paper. _________________________________________________________________________________________________ INFORMATION ABOUT YOU: Mr. or Ms. _________________________________________________________________________________________ First Name Middle Name Last Name Date of Birth _______________________________________________________________________________(____)_____________ Home Address City State Zip Code Home Telephone _________________________________________________________________________________________________ Place of Employment Trade/Occupation ________________________________________________________________________________(____)___________ Work Address City State Zip Code Work Telephone ________________________________________________________________________________(____)____________ Spouse/Partner's Name Trade/Occupation Date of Birth Work Telephone INFORMATION ABOUT THE SELLER: 1. _____________________________________________________________________________(____)__________ Name of the Business Telephone 2. _____________________________________________________________________________(____)___________ Business Address City State Zip Code 3. _____________________________________________________________________________(____)____________ Name of Salesperson Position or Title Telephone 4. _____________________________________________________________________________(____)____________ Other persons involved Position/Title Telephone _____________________________________________________________________________(____)____________ _____________________________________________________________________________(____)____________ Did you know the salesperson/company prior to this investment? • No • Yes If Yes, please explain: _________________________________________________________________________________________________ 1 American LegalNet, Inc. www.USCourtForms.com INFORMATION ABOUT THE OFFER A. How was the offer to invest/purchase made: (check One) (Attach copies of documents) • Telephone • Personal Visit ____________________________________________ _____________________________________________ (Who Called & Date) (Who Visited & Date) • Seminar or Group Sales Presentation • Newspaper/Magazine ____________________________________________ (Place of Seminar/Presentation & Date) _____________________________________________ (Name of Newspaper/Magazine & Date) • Other: Explain (Include date) ____________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ B. Where was the offer made? _______________________________________________________________________ Location Address City State Zip code C. Who made the offer? ____________________________________________________________________________ Name Position/Title D. Who else was present? (Name, Address, City, State, Zip Code, Telephone ) __________________________________________________________________________(____)_______________ __________________________________________________________________________(____)_______________ __________________________________________________________________________(____)_______________ INFORMATION ABOUT THE INVESTMENT: A. Describe the investment offered to you: (Example: common stock, oil and gas interests, etc.) ______________________________________________________________________________________________ B. Did you invest? _____________ • No • Yes When did you invest? _________________ Amount invested $ C. How did you pay? • Cash • Check (Attach a copy--Front & Back) • Other ______________________________ D. How much did you purchase? (Example: 1000 Shares: 5% working Interest, etc.) ____________________________ E. Did you sign any type of contract? • No • ______________________________ Yes (attach a copy) Date signed F. Where was the contract signed/money paid? __________________________________________________________ City/State 2 American LegalNet, Inc. www.USCourtForms.com G. Do you know any other purchasers? • No • Yes (Name, Address, City, State, Zip Code, Telephone) __________________________________________________________________________(____)_______________ __________________________________________________________________________(____)_______________ H. What were you told about the investment? ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ I. What untrue statements, if any, were made to you? ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ J. What facts, if any, did the seller omit to tell you which would have changed your decision to invest? ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 3 American LegalNet, Inc. www.USCourtForms.com ______________________________________________________________________________________________ ______________________________________________________________________________________________ INFORMATION ABOUT YOUR COMPLAINT: A. Have you communicated with any other state or federal agency? • No • Yes If Yes, please identify: 1. ___________________________________________________________________________________________ 2. ___________________________________________________________________________________________ 3. ___________________________________________________________________________________________ B. Have you hired an attorney? • No • Yes If Yes, please identify: ____________________________________________________________________________(____)_____________ Name Address City State Zip Code Telephone C. Describe your past and current investment experience: (Example: Savings Account, Mutual funds, Oil & Gas interests, etc.) ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ D. Are you willing to testify in an administrative hearing or court of law regarding this case? • No • Yes E. Are you willing to permit the Iowa Securities Bureau to share information from this Questionnaire with other government departments and/ or law enforcement agencies? • No • Yes F. Are you willing to permit the Iowa Securities Bureau to share information from this Questionnaire with the firm or party your complaint is against in order to resolve the conflict? • No • Yes ________________________________________________________ Signature ________________________________ Date ________________________________________________________ Signature ________________________________ Date 4 American LegalNet, Inc. www.USCourtForms.com