Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL CRD #: U6 ­ SUBJECT OF ACTION FIRST NAME: MIDDLE NAME: LAST NAME: SUFFIX: ALIAS: DOB(DD/MM/YYYY): SSN: CRD #: RESIDENTIAL STREET ADDRESS LINE 1: RESIDENTIAL STREET ADDRESS LINE 2: CITY: STATE: COUNTRY: ZIP/POSTAL CODE: RESIDENTIAL STREET ADDRESS LINE 1: RESIDENTIAL STREET ADDRESS LINE 2: CITY: STATE: COUNTRY: ZIP/POSTAL CODE: BUSINESS STREET ADDRESS LINE 1: BUSINESS STREET ADDRESS LINE 2: CITY: STATE: COUNTRY: ZIP/POSTAL CODE: REGULATOR CONTACT: REGULATOR PHONE NUMBER: Page 1 of 16 American LegalNet, Inc. www.FormsWorkFlow.com Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL CRD #: DISCLOSURE REPORTING PAGES U6 - BANKRUPTCY/SIPC/COMPROMISE WITH CREDITORS DRP 1. Action Type (select appropriate item): Rev. DRP (05/2009) O Bankruptcy [Circle one: Chapter 7, Chapter 11, Chapter 13, Other] O Compromise O Declaration O Liquidation O Receivership 2. Action Date (MM/DD/YYYY) (Provide date bankruptcy was filed, or date SIPC was initiated, or date of compromise with creditor):_____________________________ If not exact, provide explanation: O Other:_________________________ O Exact O Explanation 3. If the financial action relates to an organization over which the subject exercise(d) control, provide: A. Organization Name:____________________________________________________________________ B. Position, title or relationship:____________________________________________________________________ C. Investment-related business? 4. Court action brought in: O Yes O No O Federal Court O State Court O Foreign Court O Other:_________________________ A. Name of Court:____________________________________________________________________ B. Location of Court (City or County and State or Country):______________________________________________________________ C. Docket/Case#:______________ Check this box if the Docket/Case# is your SSN, a Bank Card number, or a Personal Identification Number. 5. Is action currently pending? O Yes O No 6. If not pending, provide Disposition Type (select appropriate item): 7. O Discharged O Dismissed O Dissolved O SIPA Trustee Appointed O Other:__________________________ Disposition Date (MM/DD/YYYY):________________________________ O Exact O Explanation If not exact, provide explanation: O Direct Payment Procedure O Satisfied/Released 8. If a compromise with creditors, provide: A. Name of Creditor:____________________________________________________________________ B. Original amount owed: $____________ C. Terms/Compromise reached with creditor: 9. If a SIPA trustee was appointed or a direct payment procedure was begun: A. Provide the amount paid or agreed to be paid by the subject: $____________ ; or The name of the Trustee:____________________________________________________________________ B. Currently Open? O Yes O No C. Date Direct Payment Initiated/Filed or Trustee Appointed (MM/DD/YYYY):_________________________ O Exact O Explanation If not exact, provide explanation: 10. Comment (Optional). You may use this field to provide a brief summary of the circumstances leading to the action as well as the current status or final disposition. Include the details as to creditors, terms, conditions, amounts due and settlement schedule (if applicable). Your information must fit within the space provided. Rev. DRP (05/2009) Page 2 of 16 American LegalNet, Inc. www.FormsWorkFlow.com Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL CRD #: U6 - CIVIL JUDICIAL DRP 1. Court Action initiated by: A. (Select appropriate item): O SEC O Other Federal Agency 2. Relief Sought: (select all that apply): O Jurisdiction O Foreign Financial Regulatory Authority O Firm O Private Plaintiff B. Name of party initiating the proceeding:___________________________________________ 3. Injunction Restraining Order Monetary Penalty other than Fines Other:______________________ Restitution O Exact O Explanation A. Filing Date of Court Action (MM/DD/YYYY):_________________ If not exact, provide explanation: B. Date notice/process was served (MM/DD/YYYY):_________________ If not exact, provide explanation: Cease and Desist Civil and Administrative Penalty(ies)/Fine(s) Disgorgement O Exact O Explanation 4. Product Type(s): (select all that apply) No Product Annuity-Charitable Annuity-Fixed Annuity-Variable Banking Product (other than CD) CD Commodity Option Debt-Asset Backed Debt-Corporate Debt-Government Debt-Municipal 5. Formal Action was brought in: Derivative Direct Investment-DPP & LP Interest Equipment Leasing Equity Listed (Common & Preferred Stock) Equity-OTC Futures Commodity Futures-Financial Index Option Insurance Investment Contract Money Market Fund Mutual Fund Oil & Gas Options Penny Stock Prime Bank Instrument Promissory Note Real Estate Security Security Futures Unit Investment Trust Viatical Settlement Other:____________________ O Federal Court O State Court O Foreign Court O Military Court O Other:________________________________ A. Name of Court:____________________________________________________________________ B. Location of Court (City or County and State or Country):___________________________________________________________ C. Docket/Case#:______________ 6. Employing Firm when activity occurred which led to the civil judicial action:________________________________________________ 7. Describe the allegations related to this civil action. (Your information must fit within the space provided.): 8. Current Status? O Pending O On Appeal O Final 9. If pending and any limitations or restrictions are currently in effect, provide details: Page 3 of 16 American LegalNet, Inc. www.FormsWorkFlow.com Rev. Form U6 (05/2009) INDIVIDUAL NAME: INDIVIDUAL CRD #: U6 ­ CIVIL JUDICIAL DRP (CONTINUED) 10. If on appeal: A. Action appealed to (provide name of court):____________________________________________________ B. Court Location:_______________________________________________________________ C. Docket/Case#:______________ D. Date appeal filed (MM/DD/YYYY):_____________________ If not exact, provide explanation: Rev. DRP (05/2009) O Exact O Explanation E. Appeal details (including status): F. If on Appeal and any limitations or restrictions are currently in effect, provide details: If Final or On Appeal, complete all items below. For Pending Actions, complete Item 13 only. 11. Resolution Detail: A. How was matter resolved? (select appropriate item): O Consent O Vacated O Withdrawn O Judgment Rendered O Vacated Nunc Pro Tunc / ab initio O Other:_