State of New Jersey OFFICE OF THE ATTORNEY GENERAL DEPARTMENT OF LAW AND PUBLIC SAFETY DIVISION OF CONSUMER AFFAIRS BUREAU OF SECURITIES P.O. BOX 47029 153 HALSEY STREET NEWARK, NEW JERSEY 07101 (973) 504 - 3600 E–MAIL: AskBureauofSecurities@dca.lps.state.nj.us Please be advised that any information you supply on this application may be subject to public disclosure. If an investigation into the matter is conducted, the information is subject to public disclosure only after the completion of the investigation. You are also advised that the completed complaint form is a “government record,” which the Bureau of Securities may be obligated to provide to anyone making a request pursuant to the Open Public Records Act (OPRA). COMPLAINT REPORTED BY: COMPLAINT REPORTED AGAINST: NAME:_________________________________________ FIRM NAME: ____________________________________ ADDRESS: ______________________________________ ADDRESS: ______________________________________ CITY:__________________________________________ CITY:__________________________________________ STATE: _______________________ ZIP:____________ STATE: _______________________ ZIP:____________ HOME TELEPHONE NUMBER: _________________________ TELEPHONE NUMBER (1): ___________________________ WORK TELEPHONE NUMBER: ________________________ TELEPHONE NUMBER (2): ___________________________ E-MAIL ADDRESS: ________________________________ The Bureau of Securities investigates complaints against individuals and firms selling securities or offering investment advice as well as companies issuing securities investments. The Bureau is empowered to bring administrative actions or civil law suits to enforce the registration and anti–fraud provisions of the New Jersey Uniform Securities Act. The Bureau may refer certain matters for criminal prosecution. 1. Type of firm (if known). Please check the appropriate box: Securities Brokerage Firm Investment Advisory Firm Financial Planning Firm Other (specify): ________________________________________ 2. Name and title of firm’s agents or employees with whom you dealt:______________________________________________ ____________________________________________________________________________________________________ If known, type of professional designation used: Stockbroker (Agent) 3. Investment Advisor Other (specify):_____________________________ How was the initial solicitation made: Telephone Mail Seminar Other (specify): ________________________________________ 4. Type of investment product involved in your complaint: Stocks Bonds Mutual Funds Limited Partnerships Please continue on reverse side Do not write below this line Date received: __________________________ Status #: _______________________________ Data INIT: _____________________________ Case #:_________________________ Investigator: __________ American LegalNet, Inc. www.USCourtForms.com 5. 6. Other (specify) _______________________________ Did you receive a prospectus when you purchased the investment? Have you contacted the firm about your complaint? Yes No Yes No If “Yes”, please note the name and address of those you have contacted below: Name: ________________________________________ Name: ________________________________________ Address:_______________________________________ City:__________________________________________ 7. Address:_______________________________________ City:__________________________________________ State: _______________________ ZIP:____________ State: _______________________ ZIP:____________ Yes No Have you contacted another regulatory authority or law enforcement agency about your complaint? If “Yes”, please note the name and address of those you have contacted below: Name: ________________________________________ Name: ________________________________________ Address:_______________________________________ City:__________________________________________ Address:_______________________________________ City:__________________________________________ State: _______________________ ZIP:____________ State: _______________________ ZIP:____________ 8. Describe the facts of your complaint in the order in which they happened. Please print clearly. Use additional sheets of paper, if necessary. Attach copies (no originals) of any complaint-related documents, such as monthly account statements, confirmations of purchases and sales, correspondence, and any other relevant documents. ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 9. The amount of loss involved in this complaint: $ ______________ . 10. The funds used for investment were originally drawn from: Savings, Checking Certificate of Deposit IRA/Retirement Account Insurance Proceeds or Money Market Account Proceeds from another investment Other (specify): ______________________________ 11. Complaintant’s Age (optional): Under 30 51 — 60 31 — 40 61 — 70 41 — 50 Over 70 I have read this complaint, I fully understand its contents and I certify it and photocopies of the attached documents are true and correct to the best of my knowledge. ________________________________________________________ Signature* * This certification must be signed by the person completing the form. ________________________ Date 3/04 American LegalNet, Inc. www.USCourtForms.com