OFFICE OF THE ATTORNEY GENERAL SECURITIES DIVISION 200 ST. PAUL PLACE 20TH FLOOR BALTIMORE, MARYLAND 21202-2020 TELEPHONE: (410) 576-6360 COMPLAINT The purpose of this complaint form is to provide the Maryland Division o fSecurities with information necessary for the commencement of a preliminary i nvestigation of your allegatio ns. Thus, it is important for you to furnish as much detailed information as possible. All information you provide will be deemed confidential, and neither the contents nor the source of thi scomplaint will be publicly disclosed or available for public inspectio nunless formal proceedings are instituted. It is im portant that you attach copies of all written materials (includin gc hecks, contracts, advertisemen ts, pamphlets, and letters or correspondence) that may relate to your complaint. The Division appreciates your interest and cooperation. (PLEASE TYPE OR PRINT) INFORMATION ABOUT PURCHASER OR COMPLAINANT (YOU) Mr. Mrs. Ms. Dr. _______________________________________________ __________________ Last Name First Middle Todays Date ___________________________________________________ (____)______________ Home Address City State Zip Telephone Number ___________________________________________________ (____)_____________ Business Address City State Zip Telephone Number ___________________ __________ Single Married Widowed Divorced Trade or Occupation Approx. Age Are you willing to be interviewed by an investigator from this office? ________ Yes ________ No Are you willing to be a witness if formal proceedings are commenced by th eSecurities Commissioner? >>>> 2 ________ Yes ________ No INFORMATION ABOUT SUBJECT OR SELLER (If unknown, please indicate) In what company, corporation, or association did you invest: ___________________________________________________________________________ Its Name Address Telephone No. List p ersons who were involved in this transaction. ( Please use separat epages or page 6 to set forth any other available information about thes epersons.) _______________________________ _____________________________________________ Last Name First Middle Position Telephone No ___________________________________________________________________________ Address City State Zip _______________________________ _____________________________________________ Last Name First Middle Position Telephone No _______________________________ _____________________________________________ Address City State Zip How did you learn of the investment? (Check more than one if necessary and enclose copies of pamphlets or advertisements if possible). ________ Personal visit When? _________________________ ______________________________ Where? ________________________ ______________________________ Whom? _________________________ ______________________________ Who else was present? _________ ______________________________ ________ Telephone call Date? _________________________ ______________________________ From whom? ____________________ ______________________________ At what address/location was th e call received? _____________ _______________________________ ______________________________ ________ Advertising pamphlet/sales letter Mailed to you at what address/l ocation? _____________________ _______________________________ ______________________________ 2 >>>> 3 Copy of pamphlet/sales letter e nclosed?______________________ Copy of envelope attached?_____ ______________________________ ________ Newspaper Name of paper? ________________ ______________________________ Date? _________________________ ______________________________ Copy of advertisement enclosed? _____________________________ ________ Radio Name of station? ______________ ___________________________________ Date? _________________________ ___________________________________ ________ Television Name of station? ______________ ___________________________________ Date? _________________________ ___________________________________ ________ Group sales presentation Date of presentation? _________ ___________________________________ Where? ________________________ ___________________________________ Others present? _______________ ___________________________________ ________ Other (Please specify) _______________________________ ___________________________________ _______________________________ ___________________________________ L ist others who were present when the offers or sales were ma de to you. (Use page 6 if necessary). _______________________________ _____________________________________________ Name Address Telephone Relationship to Complainant (Purchaser) or Seller What did you purchase or invest in? (Examples: common stock, debenture ,l imited partnership interest, i nvestment contract, fractional interest in an oil and gas lease) _______________________________ _____________________________________________ _______________________________ _____________________________________________ How many units or shares did yo u purchase? _________________________________ Total amount of your investment or loan? $________ Cash $________ Chec kOther (Please identify) __________________ (Enclose copy of both sides o f 3 >>>> 4check) How was the amount to be paid: (lump sum, installments, etc.) ______________ _______________________________ _____________________________________________ Who received the payment from y ou? _________________________________________ When? _________________________ ________________________________________ Where? ________________________ ________________________________________ By Mail? ______________________ ________________________________________ On what dates were the units or shares purchased? __________________________ Did you sign any type of contract? ________ If so, please enclose a copy. Where was it signed (city/count y)? ____________________________________ Who else was present? _________ ________________________________________ How were your securities delive red? ________________________________________ If in person: By whom? ______________________ ___________________________________ When? _________________________ ___________________________________ Where? ________________________ ___________________________________ If by mail, please attach envelope and any cover letter. Descri be any prior business or personal relationships/dealings with eithe rt he company or the salesperson who cont