COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : FIS 0500 (5/02) Michigan Office of Financial & Insurance Services Securities Complaint Form -against- : Calendar No. : Consumer Services Division Plaintiff(s) Index No. JUDICIAL SUBPOENA : COMPLAINANT INFORMATION (identifies you as the Complainant) : _____________________________________________________________________________________ : Your Last Name First Middle Initial Defendant(s) : . ._____________________________________________________________________________________ .................................................... Residence Address (Street, City, State and Zip Code) _____________________________________________________________________________________ THE PEOPLE OF THECity, State and Zip Code) Business Address (Street, STATE OF NEW YORK TO _____________________________________________________________________________________ Occupation Business Telephone Number Residence Telephone Number I DECLARE GREETINGS:I HAVE A COMPLAINT AGAINST: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend _____________________________________________________________________________________ before , the Honorable Company, Firm, Person at the Court Name of Business, located at County of in______________________________________________________________________________________________________recessed room , on the day of , 20 , at o'clock in the noon, and at any orStreet addressdate, to testify and give suite number, or apartment in this action on the part of the adjourned of Business (room number, evidence as a witness number, if any) ______________________________________________________________________________________________________ City State Zip Code Business Telephone Number Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to How and when did you first hear of the investment opportunity (e.g. advertisement in and Street Journal, the party on whose behalf this subpoena was issued for a maximum penalty of $50 Wall all damages sustained as a telephone solicitation comply. result of your failure toor Internet contact). ______________________________________________________________________________________________________ Witness, Honorable , one of the Justices of the Court in County, day of , 20 ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ (Attorney must sign above and type name below) ______________________________________________________________________________________________________ Full names of salesperson, agent or other representative and/or names of any principals of the business entity. Attorney(s) for ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Office and P.O. Address Telephone No.: "This form is issued under Section 407, Act 265, PA 1964, as amended." Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : Please explain the type of investment (i.e., stock, bonds, limited partnership, note, viatical settlement, JUDICIAL SUBPOENA Plaintiff(s) contract, etc.) -against- : _____________________________________________________________________________________ : _____________________________________________________________________________________ : _____________________________________________________________________________________ Defendant(s) : ...................................................... _____________________________________________________________________________________ Place(s) where transaction(s) occurred. THE PEOPLE OF THE STATE OF NEW YORK Amount(s) Invested _____________________________________________________________________________________ TO _____________________________________________________________________________________ GREETINGS: Have you contacted the business or person regarding your complaint? Yes No WE COMMAND _______________________________________________________________ If yes, person(s) contactedYOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of Results of contact: ______________________________________________________________________ in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the _____________________________________________________________________________________ _____________________________________________________________________________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party onfiled this behalf thiswith another lawissued for a maximum penalty of $50 and all damages sustained as a Have you whose complaint subpoena was enforcement or consumer protection agency? ___________ result of your failure to comply. _____________________________________________________________________________________ Witness, Honorable , one of the Justices of the Court in County, day of , 20 _____________________________________________________________________________________ Are you willing to appear as a witness, be sworn, testify and be cross-examined concerning the allegations made in this complaint? Yes No (Attorney must sign above and type name below) If no, state the reason: __________________________________________________________________ Attorney(s) for _____________________________________________________________________________________ _____________________________________________________________________________________ Please estimate your net worth including autos and house. $10,000 - 25,000 $25,000 – 50,000 Office and P.O. Address $50,000 – 100,000 $150,000 – 200,000 Telephone No.: $100,000 – 150,000 $200,000 – or more Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. Please explain in detail your previous investment experience. Indicates types of investments, amount invested and dates invested. Plaintiff(s) : JUDICIAL SUBPOENA _____________________________________________________________________________________ -against: _____________________________________________________________________________________ : _____________________________________________________________________________________ : Defendant(s) : . ._____________________________________________________________________________________ .................................................... _____________________________________________________________________________________ THE PEOPLE OF THE STATE financial experience of someone other than yourself? Yes Did you rely on the business or OF NEW YORK No TO yes, who? Please give details: __________________________________________________________ If _____________________________________________________________________________________ GREETINGS: _____________________________________________________________________________________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before _____________________________________________________________________________________ , the Honorable at the Court located at County of available the inPlease check below which of the following documents are attached or o'clock into incorporate as part of recessed room , on the day of , 20 , at noon, and at any orthis complaint. to testify and give evidence as a witness in this action on the part of the adjourned date, Attached Available Type of Document Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to ________ ________ Advertising materials the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. ________ ________ Agreement/Contract ________ ________ Witness, Honorable ________ ________ Court in County, Promissory Note (if applicable) Cash Receipt(s) day of , 20 , one of the Justices of the ________ ________ Cancelled Check(s) (front and back) ________ ________ Brochures/Prospectuses (Attorney must sign above and type name below) ________ ________ Copies of all documents which relate to your complaint and which are not listed above. Attorney(s) for List the names, addresses and phone numbers of other individuals who may have invested, or may have further knowledge of the investment. _____________________________________________________________________________________ Office and P.O. Address _____________________________________________________________________________________ Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. In a brief statement tell us the full story beginning with the date of the first contact to present. Keep dates : JUDICIAL and 2). Include of events in sequence and include misrepresentations. (Refer to Guidelines on pages 1 SUBPOENAfull Plaintiff(s) names of all witnesses present during the transaction(s). Be factual. Keep in mind “Who, What, Where -against: and When.” Attach extra sheets if necessary. : _____________________________________________________________________________________ : _____________________________________________________________________________________ Defendant(s) : ...................................................... _____________________________________________________________________________________ _____________________________________________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK _____________________________________________________________________________________ TO _____________________________________________________________________________________ _____________________________________________________________________________________ GREETINGS: _____________________________________________________________________________________ before WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend , the Honorable at the Court _____________________________________________________________________________________ located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or_____________________________________________________________________________________ adjourned date, to testify and give evidence as a witness in this action on the part of the _____________________________________________________________________________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you _____________________________________________________________________________________ liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. _____________________________________________________________________________________ Witness, Honorable , one of the Justices of the _____________________________________________________________________________________ Court in County, day of , 20 _____________________________________________________________________________________ (Attorney must sign above and type name below) _____________________________________________________________________________________ _____________________________________________________________________________________ Attorney(s) for _____________________________________________________________________________________ _____________________________________________________________________________________ Office and P.O. Address _____________________________________________________________________________________ _____________________________________________________________________________________ Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. _____________________________________________________________________________________ Plaintiff(s) : JUDICIAL SUBPOENA _____________________________________________________________________________________ -against: _____________________________________________________________________________________ : _____________________________________________________________________________________ : Defendant(s) : . ._____________________________________________________________________________________ .................................................... _____________________________________________________________________________________ THE PEOPLE OF THE STATE OF NEW YORK _____________________________________________________________________________________ TO _____________________________________________________________________________________ _____________________________________________________________________________________ GREETINGS: _____________________________________________________________________________________ WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before _____________________________________________________________________________________ , the Honorable at the Court located at County of in_____________________________________________________________________________________recessed room , on the day of , 20 , at o'clock in the noon, and at any or adjourned date, to testify and give evidence as a witness in this action on the part of the _____________________________________________________________________________________ _____________________________________________________________________________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a _____________________________________________________________________________________ result of your failure to comply. _____________________________________________________________________________________ Witness, Honorable Court in County, , one of the Justices of the day of , 20 I hereby affirm that the foregoing statements and photo copies of all attached documents are true and correct. (Attorney must sign above and type name below) _______________________________ Date _____________________________________________ Signature of Complainant for Attorney(s) When complete, please send the form along with supporting documents to: Consumer Services Division P.O. Box 30220 Lansing, Michigan 48909-7720 This and P.O. Address Office form is available in PDF format from our Web site at: http://www.cis.state.mi.us/ofis Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : INSTRUCTIONS FOR COMPLETING THE COMPLAINT FORM : Index No. Calendar No. : JUDICIAL SUBPOENA Before filling out the attached compliant form, please take the time to read these instructions; they will help Plaintiff(s) you understand our functions, and we will be better able to understand and act on your complaint. -against: WHAT WE CAN DO : We investigate complaints against persons and business : entities accused of violating the registration and antifraud provisions of the Michigan Uniform Securities Act. We are empowered to Defendant(s) : . . . . . . . . bring .administrative. actions to. stop. the. violations, .and. in.appropriate cases, to refer matters to the .... .......... ....... ... .. ........ .. . . Department of Attorney General for civil actions or criminal prosecution. ! ! The Michigan Uniform Securities Act regulates the sale of securities in or from Michigan and THE PEOPLE OFthe registrationOF securities industry professionals (broker-dealers, agents and investment requires THE STATE of NEW YORK advisers). If you have a problem relating to the purchase or sale of a security, we may be able to assist with a resolution of the problem; however, please note the limitations on our authority to take action described below. TO WHAT WE CANNOT DO GREETINGS: ! WE cannot act as a court that all so we cannot excuses being laidbe refunded, contracts be attend before We COMMAND YOU, of law, business and order that monies aside, you and each of you cancelled, damages be awarded, etc. If you the this type of Court you should consult an problem , the Honorable at have attorney. located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed ! We cannot testify and attorney. or adjourned date, to act as your give evidence as a witness in this action on the part of the We cannot take action in matters involving the internal affairs of a business entity. We only have jurisdiction over the offer, sale or purchase of securities, not over the way business is being Your failure to comply with thissecurities industry professionals (broker-dealers,and will make you liable to conducted except in the case of subpoena is punishable as a contempt of court agent and the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a investment advisers). ! result of your failure to comply. HOW YOU CAN HELP US Witness, Honorable , one of the Justices of the Court in County, day of , 20 Summarize your complaint using these guidelines: include how you first learned of the investment (advertisement, personal contact). ! Tell us WHAT happened. Start from the beginning. Be(Attorney mustto what was said and who said specific as sign above and type name below) it. ! Tell us WHO was present during these conversations or acts. Attorney(s) for ! Tell us WHEN and WHERE these conversations/acts took place. ! Tell us WHEN and WHERE the money and agreements changed hands. Office and P.O. Address ! Tell us HOW you know the representations were false or HOW you know your money was misused. Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. Attach photocopies of all documents such as contracts, agreements, certificates, notes, trust deeds, correspondence, legible copies of the front and back of checks involved, prospectus, advertising, etc. : Documentary evidence is especially important. Please do not send JUDICIAL cannot be originals; we SUBPOENA Plaintiff(s) responsible for their safekeeping. -against: Type or print clearly in ink. : Mail the form along with supporting documents to: : Defendant(s) : . . . . . . . . Office . . . . . . . . . . and . . . . . . . . .Services. . . . . . . . . . . . . . . . . . of Financial . . . Insurance . . . . . . Consumer Services Division P.O. Box 30220 Lansing, Michigan 48909-7720 THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com