ROBIN CARNAHAN JAMES C. KIRKPATRICK STATE INFORMATION CENTER (573) 751-4936 SECRETARY OF STATE STATE OF MISSOURI MATTHEW D. KITZI COMMISSIONER OF SECURITIES (800) 721-7996 Complaint Information Sheet Investor Information  Mr.  Mrs. Your Name  Ms. ____________________________________________ Date of Birth _________________ Address _____________________________________________________________________________________ City _____________________________________________ State ___________ Zip _______________________ Home Telephone ( Email address ) ________________________ Business Telephone ( )_________________________ Other Company and Salesperson Information Company and Representative Information Name of Company____________________________________ Representative Address_____________________________________________________________________________________ City__________________________________________ State_______________ Zip Telephone ( ) Complaint Information Please provide a brief summary of your complaint in the space provided below. If you feel that additional space is needed, feel free to use the space provided on the back of this form. Please answer the questions on the next page as well; this allows our staff to gather the most pertinent information to aid in our review of your complaint. American LegalNet, Inc. www.FormsWorkflow.com Investment Information 1. Explain what you were offered: ______________________________________________________________ ___________________________________________________________________________________________ 2. How much money did you invest? _________________Payment was made by: ____ cash ____ check ____ other 3. Date of investment(s): ________________________________Place of Investment(s):___________________ 4. Please give a brief explanation of how you gained knowledge of this investment and exactly what you were told about the investment. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________ a. What were you told your money would be used for? _______________________________________________ _____________________________________________________________________________________________ b. What amount of return were you promised? ______________________________________________________ c. What were you told about the risks of this investment? _____________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ d. Did you receive a prospectus or other information regarding the financial condition of the company? ____________________________________________________________________________________________ e. Did the seller give you information that later turned out to be untrue? _____________________________________ If yes, please explain: ___________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________________________ f. 5. Did you sign a contract? _____________________________________________________________________ Have you contacted an attorney or any other government agency? _______________________________________ If yes, who?__________________________________________________________________________________ 6. Have you asked for the return of your initial investment? ______________If so, did you receive it? ____________ 7. Please provide the names, addresses, and telephone numbers of any body else that you know that made the same investment or dealt with the same representative: ___________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com Documents 8. Please attach copies of the following documents: Stock certificates/bonds/investment certificates Confirmations of purchases Cancelled checks (front and back) Contracts Any other documentation or advertising relating to the investment Signature: _____________________________________________________ Printed name: _________________________________________________ Date: ____________________ Please be advised that this Division is prohibited by law from giving you legal advice, legal opinions, or acting as your private attorney. Therefore, you may wish to consult with a private attorney to discuss your legal rights and remedies. If you have any question about this form, please call the investor hotline at: 1 (800)-721-7996. Please mail all correspondence to: Office of the Secretary of State Securities Division PO Box 1276 600 W.Main St. Jefferson City, MO 65102 To send your complaint via e-mail: securities@sos.mo.gov (If you file your complaint via the internet or via e-mail be sure and send the documents requested above.) American LegalNet, Inc. www.FormsWorkflow.com