COMPLAINT FORM NORTH DAKOTA SECURITIES DEPARTMENT SFN 14927 (2-2013) Department Use Only Case Number Name: (Your full name - please print) Residence Address: City: State: ZIP Code: Residence Telephone Number: E-Mail Address Business Address: City: State: ZIP Code: Business Telephone Number: E-Mail Address Occupation: Date of Birth: IN ADDITION TO COMPLETING THIS FORM, PLEASE ALSO ATTACH THE FOLLOWING: I. A summary of your complaint in your own words, including: a.) HOW you first learned of the investment (ad, personal contact, etc.) b.) WHAT happened. Start from the beginning. Be specific as to what was said and who said it. c.) WHO was present during these conversations or acts. d.) WHEN and WHERE these conversations/acts took place. e.) WHEN and WHERE the money and agreements changed hands. f.) II. HOW you know the representations were false or HOW you know your money was misused. Copies of documents such as contracts, agreements, certificates, notes, trust deeds, correspondence, legible copies of the front and back of checks involved, escrow documents, advertising, etc. (Please do not send originals.) If you have questions concerning this form, you may call the Securities Department's office at 701-328-2910 during regular business hours or 800-297-5124 (in-state toll free number). After completing this form, please mail, email, or fax the form along with your summary and copies of documents to: Securities Department State Capitol - 5th Floor 600 E Boulevard Ave Dept 414 Bismarck ND 58505-0510 Email: ndsecurities@nd.gov Fax: 701-328-2946 www.nd.gov/securities American LegalNet, Inc. www.FormsWorkFlow.com SFN 14927 (2-2013) Page 2 of 4 1. Briefly describe the nature of your complaint. 2. List the full name, address, telephone number, web address, and e-mail address of the business, company, firm, or person that asked you to invest. 3. How did you first hear of the investment opportunity (such as newspaper ad, telephone solicitation, personal contact, etc.)? 4. When did you first hear of the investment opportunity? 5. Please list the full names of each officer, director, salesperson, agent, or any other representatives of the company that you know of. 6. What type of investment (such as gold, silver, oil and gas, etc.) was offered to you? 7. Were you told how your money was going to be used? If so, please write what you were told by the salesperson. Yes No American LegalNet, Inc. www.FormsWorkFlow.com SFN 14927 (2-2013) Page 3 of 4 8. List the amounts you invested and the dates of your investments. 9. How was the money sent to the company (such as wire transfer, federal express, United States mail, etc.)? 10. Where did the sale take place? If the sale took place via the telephone, where were you when the sale was made? 11. Did you know of any license or registration of this company or any of its representatives issued by any agency (such as National Futures Association, Commodities Futures Trading Commission, Attorney General, etc.)? 12. Have you contacted the company or any of its representatives regarding your complaint? If so, what was the name of the person(s) and how and when did you contact them? Yes No What was the result of your contact? 13. Have you filed this complaint with any other law enforcement or consumer protection agency? Yes No If so, please list the name and address of the agency and the name of the person handling your complaint. American LegalNet, Inc. www.FormsWorkFlow.com SFN 14927 (2-2013) Page 4 of 4 14. Have you started any civil action (lawsuit) in this matter in any court, or do you know of any action filed by any Yes No other investors? If so, please provide details such as the title of the action, the court in which it is filed, date filed, etc. 15. Are you willing to appear as a witness, testify under oath, and be cross-examined about this matter? Yes No 16. Please list the names, addresses and telephone numbers of other individuals that you know of who may have invested in this company, or who have been contacted about making an investment. 17. Please list the names, addresses and telephone numbers of any witnesses to the transaction, or anyone else you know of that may have any information regarding this matter. 18. Please indicate by a check mark what copies you have attached to this complaint. Advertising Materials Brochures Prospectus Newsletters Contract/Agreement Canceled Checks (front & back) Warehouse Receipts Others PLEASE REMEMBER TO ATTACH A BRIEF STATEMENT TELLING US THE FULL STORY OF YOUR COMPLAINT. KEEP THE DATES IN ORDER, AND INCLUDE ANY MISREPRESENTATIONS. PLEASE ATTACH SEPARATE SHEETS FOR THIS PURPOSE. I HEREBY DECLARE THAT THE ABOVE STATEMENTS AND ATTACHED STATEMENTS AND PHOTOCOPIES ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. Signature Date American LegalNet, Inc. www.FormsWorkFlow.com