INVESTOR COMPLAINT FORM DIRECTIONS: The information you provide on this form is important to enable the Division to investigate your complaint. Note that this Division cannot guarantee monetary recovery on your behalf. Please furnish specific and detailed information, answer all questions which are applicable to your situation, and be clear and complete in your answers. Failure to provide all relevant information may delay the processing of your complaint. ===================================================================== I. INVESTOR INFORMATION Full Name ___________________________________________ Date ___________________ Address _____________________________________________ County _________________ City/State/Zip ________________________________________ Work Phone _____________ Occupation ___________________________________________ Home Phone _____________ Cell Phone_____________________________ II. FACTS AND CIRCUMSTANCES Email ____________________________________ 1. Against whom are you filing this complaint? Please provide name, address, and telephone. ____________________________________________________________________________________ ____________________________________________________________________________________ 2. Date and means of initial contact (E.g., newspaper ad, mail, telephone solicitation, referral, etc.). Who made the initial contact? ____________________________________________________________________________________ ____________________________________________________________________________________ 1 American LegalNet, Inc. www.FormsWorkFlow.com 3. State the full name of the person who sold the investment to you. ___________________________________________________________________________________ ___________________________________________________________________________________ 4. Other names associated with the person who sold the investment to you, such as a brokerage firm, company, or other principals or associates, etc. Please provide names, addresses and telephone numbers. ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 5. The following information relates to the actual investment you made. Please provide complete factual data. a. Name of Investment ________________________________________________________________ b. Type of Investment (E.g., stocks, bonds, limited partnership interests, joint venture, etc.) ___________________________________________________________________________________ c. Date of Investment _________________________________________________________________ d. Number of Shares or Interests Purchased ________________________________________________ e. Price per Share/Total Purchase Price ___________________________________________________ f. Where did this transaction take place? Who was present? ___________________________________________________________________________________ ___________________________________________________________________________________ g. How did you pay for this investment (E.g., cash, check, money order, wire transfer, etc.)? ___________________________________________________________________________________ 6. What were you told that made you decide to invest, such as, the type of profits you might receive, how risky or safe the investment would be, information about the future value of your investment, etc.? Who told you this? ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 2 American LegalNet, Inc. www.FormsWorkFlow.com 7. What were you told about how the company was going to use your funds? ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 8. Did you make the company/salesperson aware of your financial situation, investment objectives, and/or your risk tolerance? If so, what was said, to whom, and when? ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 9. How frequently were you in contact with the company/your salesperson? With whom were you in contact and what did you discuss? ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 10. Were you encouraged to invest more money in the same or similar investment? If so, what was said to you, by whom, and when? ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 11. Specifically, describe your complaint: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ 12. Have you calculated or evaluated your losses? ________ If so, did you have someone assist you with the evaluation, such as an attorney or CPA? ____________ If not, how did you evaluate any losses, and what was the result of this evaluation? _____________________________________________________________________________ _____________________________________________________________________________ 3 American LegalNet, Inc. www.FormsWorkFlow.com 13. How would you like your complaint to be resolved? Please be specific. ____________________________________________________________________________________ ____________________________________________________________________________________ 14. Describe any contacts you have had with the