CLAIM INFORMATION SHEET I. PARTIES CLAIMANT(S): (Provide this information even if you are represented by counsel.) Name Address City State Zip Code Daytime Telephone Fax # Email Address Residence during the time of the dispute (if different from above): Name Address City State Claimant is a: Public customer Broker-dealer Zip Code Person associated with a broker-dealer If you checked “Broker-dealer” or “Person associated with a broker-dealer,” it is important that you provide the correct BD/CRD number. To determine whether a party is a FINRA firm or associated person, you may consult FINRA’s BrokerCheck program on the Web at www.finra.org/BrokerCheck. BD # CRD # Claimant’s Counsel/Representative (if applicable): (Note: FINRA requires that persons representing Florida investors in arbitration proceedings conducted in or outside of the State of Florida affirm either that they are licensed to practice law and provide a bar identification number, or that they are not receiving compensation in connection with representing the party in the arbitration proceeding.) Name Bar ID # (if applicable) Address City State Zip Code Business Telephone Fax # Email Address If needed, copy this page to list additional claimants. 14 American LegalNet, Inc. www.FormsWorkFlow.com CLAIM INFORMATION SHEET RESPONDENT(S) Respondent #1: Name Address (if known) City State Zip Code Business Telephone Fax Email Address Respondent #1 is a: Public customer Broker-dealer Person associated with a broker-dealer If you checked “Broker-dealer” or “Person associated with a broker-dealer,” it is important that you provide the correct BD/CRD number. To determine whether a party is a FINRA firm or associated person, you may consult FINRA’s BrokerCheck program on the Web at www.finra.org/BrokerCheck. BD # CRD # Respondent #2: Name Address (if known) City State Zip Code Business Telephone Fax # Email Address Respondent #2 is a: Public customer Broker-dealer Person associated with a broker-dealer If you checked “Broker-dealer” or “Person associated with a broker-dealer,” it is important that you provide the correct BD/CRD number. To determine whether a party is a FINRA firm or associated person, you may consult FINRA’s BrokerCheck program on the Web at www.finra.org/BrokerCheck. BD # CRD # If needed, copy this page to list additional respondents. 15 American LegalNet, Inc. www.FormsWorkFlow.com CLAIM INFORMATION SHEET II. CLAIMS Accounts: If the dispute or claim involves activity with respect to an account or accounts, please list each account and indicate the type of account it is (e.g., joint account, custodial account, etc.) 1. Name (exactly as it appears on the account) Type of Account Name of Firm and Branch Office Date Account Opened Name of Registered Representative 2. Name (exactly as it appears on the account) Type of Account Name of Firm and Branch Office Date Account Opened Name of Registered Representative 3. Name (exactly as it appears on the account) Type of Account Name of Firm and Branch Office Date Account Opened Name of Registered Representative If needed, copy this page to list additional accounts. 16 American LegalNet, Inc. www.FormsWorkFlow.com CLAIM INFORMATION SHEET Type of Dispute: (Check where applicable) a. Account Related Breach of Contract Exchanges Transfer Collection Failure to Supervise Other Dividends Margin Calls Errors/Charges Negligence b. Executions Execution Price Incorrect Quantity Failure to Execute Limit Versus Market Order c. Account Activity Breach of Fiduciary Duty Misrepresentations Unauthorized Trading Churning Omission of Facts Other Manipulations Suitability d. Employment Breach of Contract Discrimination National Origin Partnerships Commissions Discrimination Race Promissory Notes Compensation Discrimination Religion Sexual Harassment Discrimination Age Discrimination Sexual Preference Training Contracts Discrimination Disability Libel or Slander Wrongful Termination Discrimination Gender Libel or Slander on Form U-5 Other e. Trading Dispute Buy-In Markups Transfers D.K.s Sell Outs Other Manipulation Stock Loan f. Other Clearing Dispute Indemnification Underwriting Defamation Raiding Disputes Other Other 17 American LegalNet, Inc. www.FormsWorkFlow.com g. Type of Security(ies), Financial Instrument(s), and/or Investment(s) involved in the Dispute: Annuities “Fannie Maes” Options Variable Annuities “Freddie Macs” Preferred Stock Auction-Rate Securities Certificates of Deposit Futures Private Equities “Ginnie Maes” Real Estate Investment Trust Collateralized Debt Obligations (CDOs) Government Securities Repurchase Agreements Collateralized Mortgage Obligations (CMOs) Hedge Funds Reverse Convertibles Commodities (Other than Futures) Limited Partnerships Reverse Repurchase Agreements Common Stock Municipal Bonds Stock Index Futures Corporate Bonds Municipal Bond Funds Structured Products Exchange-Traded Funds Mutual Funds Warrants/Rights Other: 18 American LegalNet, Inc. www.FormsWorkFlow.com CLAIM INFORMATION SHEET III. RELIEF REQUESTED 1. Damages Actual Damages Requested $ 1. 2. * AMOUNT IN DISPUTE: 3. (monetary sum required to compensate a party for his or her loss excluding interests and expenses) Punitive Damages Requested (monetary amount intended to punish the wrongdoer) * Use this amount to calculate the correct filing fee and hearing session deposit in Part IV. This amount ust match the amount m stated in your claim. Interest (include calculations, if possible) 2. Other Type of Relief Requested Specific Performance (Specify the type of specific performance sought) (specific performance requires parties to take an action, such as turning over ownership of stocks) Injunctive Relief (Specify the type of injunctive relief sought) (injunctions require parties to refrain from certain actions) 3. Costs (Provide specific amounts, if known. If not known, please mark an “X” to indicate the costs you are requesting) Forum Fees Attorney’s Fees 4. Witness and Production Fees Other Case-Related Costs Panel Selection Method for Customer Cases Decided by Three Arbitrators: I am requesting the Optional All-Public Panel Rule for selecting arbitrators. ­ I am requesting the Majority-Public Panel Rule for selecting arbitrators. 19 American LegalNet, Inc. www.FormsWorkFlow.com CLAIM INFORMATION SHEET Customer or Associated Person Claimant IV. FEES TO DETERMINE THE CORRECT FEE, USE THE “AMOUNT IN DISPUTE” FIGURE ON LINE 3, PAGE 19. If you are a CUSTOMER OR ASSOCIATED PERSON CLAIMANT use this table (Rule 12900 of the Customer Code or Rule 13900 of the Industry Code) to determine the filing fee that MUST accompany a Statement of Claim when it is filed with FINRA. If your claim does NOT disclose or specify a monetary claim, the filing fee is $1,250. Find the amount of your dispute on the chart, then find the applicable claim filing fee. Filing Fees for Claims Filed by Customers, Associated Persons and Other Non-Members Amount of Claim (exclusive of interest and expenses) Filing Fee $.01 to $1,000 $50 $1,000.01 to $2,500 $75 $2,500.01 to $5,000 $175 $5,000.01 to $10,000 $325 $10,000.01 to $25,000 $425 $25,000.01 to $50,000 $600 $50,000.01 to $100,000 $975 $100,000.01 to $500,000 $1,425 $500,000.01 to $1 million $1,575 Over $ 1 million $1,800 Non-Monetary/Not Specified $1,250 Once you have determined the correct filing fee, submit it with your Statement of Claim. For example, if you are a customer or associated person claimant and the amount of your claim is $40,000, the claim filing fee is $600. Mail the check with your Statement of Claim, Claim Information Sheet and properly executed Submission Agreement. 20 American LegalNet, Inc. www.FormsWorkFlow.com CLAIM INFORMATION SHEET Firm Claimant TO DETERMINE THE CORRECT FEE, USE THE “AMOUNT IN DISPUTE” FIGURE ON LINE 3, PAGE 19. If you are a FIRM CLAIMANT use this table (Rule 12900 of the Customer Code or Rule 13900 of the Industry Code) to determine the filing fee that MUST accompany a Statement of Claim when it is filed with FINRA. If your claim does NOT disclose or specify a monetary claim, the filing fee is $1,500. Find the amount of your dispute on the chart, then find the applicable claim filing fee. Member Claimant Amount of Claim (exclusive of interest and expenses) Filing Fee $.01 to $1,000 $225 $1,000.01 to $2,500 $350 $2,500.01 to $5,000 $525 $5,000.01 to $10,000 $750 $10,000.01 to $25,000 $1,050 $25,000.01 to $50,000 $1,450 $50,000.01 to $100,000 $1,750 $100,000.01 to $500,000 $2,125 $500,000.01 to $1,000,000 $2,450 $1,000,000.01 to $5,000,000 $3,200 Over $5,000,000 $3,700 Non-Monetary/Not Specified $1,500 Once you have determined the correct filing fee, you should calculate the appropriate member surcharge outlined on page 22 and submit the total with your Statement of Claim. For example, if you are a firm claimant and the amount of your claim is $40,000, the claim filing fee is $1,450, and the member surcharge is $875. Therefore, you should send one check payable to FINRA Dispute Resolution in the amount of $2,325. Mail the check with your Statement of Claim, Claim Information Sheet and properly executed Submission Agreement. 21 American LegalNet, Inc. www.FormsWorkFlow.com CLAIM INFORMATION SHEET Member Surcharge & Process Fees Rules 12901 and 12903 of the Customer Code, and Rules 13901 and 13903 of the Industry Code require firms to pay a non-refundable surcharge and non-refundable process fees if the firm or person associated with the firm is a claimant or respondent in an arbitration at this forum. FINRA will send invoices for process fees to firms at appropriate stages of the arbitration process. TO DETERMINE THE CORRECT SURCHARGE, USE THE “AMOUNT IN DISPUTE” FIGURE ON LINE 3, PAGE 19. If you are a FIRM CLAIMANT, use this table (Rules 12901 or 13901) to determine the appropriate member surcharge that MUST accompany your Statement of Claim when it is filed with FINRA. If your claim does NOT disclose or specify a monetary claim, the non-refundable surcharge is $1,500. Member Surcharge Amount in Dispute (exclusive of interest and expenses) Surcharge Up to $2,500 $150 $2,500.01–$5,000 $200 $5,000.01–$10,000 $325 $10,000.01–$25,000 $425 $25,000.01–$30,000 $600 $30,000.01–$50,000 $875 $50,000.01–$100,000 $1,100 $100,000.01–$500,000 $1,700 $500,000.01–$1,000,000 $2,250 $1,000,000.01–$5,000,000 $2,800 $5,000,000.01–$10,000,000 $3,350 Over $10,000,000 $3,750 Non-Monetary/Not Specified $1,500 V. HEARING INFORMATION For claims of $50,000 or less under Rules 12800 (simplified customer/investor) and 13800 (simplified industry): (check one) I am requesting a hearing in this matter I am not requesting a hearing in this matter 22 American LegalNet, Inc. www.FormsWorkFlow.com