CONSUMER'S COMPLAINT REGARDING SECURITIES OR INVESTMENTS ____________________________ Your Name (please print or type) ____________________ Daytime telephone number ______________________________ Email Address ___________________________________________________________________________________ Your Address: Street City State Zip Code County _______________________________________ Issuer Company of Securities or Investments _________________________________________ Name of Securities Broker or Investment Advisor _____________________________________ _________________________________________ Name of Purchaser of Securities or Investments Identification Number of the Securities or Investments (you or another person on whose behalf you are filing this claim*) *Please note: If you are making a complaint on behalf of someone else (other than a minor), you must provide us with either: a letter from that person that grants you permission to inquire into the matter; or the address of that person so we may provide the summary of our investigation directly to that person. If you are making a complaint on behalf of a minor, please describe your relationship to the minor. ____________________________ Date of purchase (if known) ______________________________ Type of Securities or Investments (if known) ___________________ Date of loss (if applicable) Your Complaint ­ Please provide a brief summary of your complaint. Use additional pages if necessary. ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ __________________________________________________________________________________ Attach copies of any documents that are central to your complaint. Please submit your completed form and attachments for Iowa Insurance Division review to: Iowa Insurance Division Securities Bureau Fax to: 515-281-3059 601 Locust Street, 4th Floor OR Des Moines, Iowa 50309-3738 Email to: iowasec@iid.iowa.gov By submitting this complaint, you verify that your statements are true and, without otherwise waiving the confidentiality protection of Iowa Code sections 502.607 or 505.8, or other applicable state or federal statutes or regulations, you are authorizing the Securities Bureau of the Iowa Insurance Division to provide a copy of this complaint form and attachments to the Securities issuer, Broker-Dealer, Broker, Investment Adviser Firm, or Investment Adviser that is the subject of your complaint. _____________________________________________ Signature ______________________ Date American LegalNet, Inc. www.FormsWorkFlow.com