CSCL/LCE-992 (0) Department of Licensing and Regulatory Affairs Corporations, Securities & Commercial Licensing Bureau P.O. Box 30018, Lansing, MI 48909 Telephone: (517) 241- STATEMENT OF COMPLAINT COMPLAINANT: The Department has jurisdiction in only certain matters involving consumers and licensees in the areas listed below. If the Department has jurisdiction over your allegations, an investigation will be conducted for possible licensing action by the Department. Your individual remedies should be pursued in the civil courts. Indicate which of the following the complaint is against: Cemetery (Private) Professional Investigator Schools Security Guard Agency Unarmed Combat Vehicle Protection Product Warrantor *Attach a brief detail of the allegations. *Attach copies of all documents such as contracts, agreements, certificates, notes, correspondence, legible copies of the front and back of checks involved, prospectus, advertising, plans or specifications, etc. Please do not send originals; we cannot be responsible for their safekeeping and they will not be returned. *The Department may ask you to provide other documents at a later date to support the allegations. I understand the information provided will not be returned, will be used for investigative purposes, and may be subject to release under the Freedom of Information Act. SIGNATURE DATE THE COMPLAINT IS AGAINST INFORMATION ABOUT YOU Name of Licensee (Company) Name Address (Number and Street) Address (Number and Street) Telephone Number Telephone Number Name of Person You Dealt With E - mail address License Number (If known) Are you willing to testify in a hearing? Yes No City, State Zip Code City, State Zip Code American LegalNet, Inc. www.FormsWorkFlow.com