State of Ohio Department of Commerce Division of Securities COMPLAINT FORM DIRECTIONS: The information you provide on this form is valuable to the Division's investigation of your complaint. Please furnish specific and detailed information, answer all questions that are applicable to your situation, be clear and concise in your answers. Failure to provide complete information may delay the processing of your complaint. Full Name Date Address County City/State/Zip Work Phone Occupation Home Phone 1. Who is your complaint against (name, address, telephone number)? 2. Date and means of initial contact (i.e., newspaper ad, mail, telephone solicitation, referral, etc.) Who made the initial contact? 3. Full name of person who sold the investment to you. 4. Other names associated with the person who sold the investment to you, such as a brokerage firm, company, or other principals or associates, etc. Please include addresses and phone numbers. 5. The following information relates to the actual investment you made. complete and factual data. Please provide a. Name of Investment b. Type of Investment (i.e., stocks, bonds, limited partnership interests, etc.) American LegalNet, Inc. www.USCourtForms.com 2 c. Date of Investment d. Number of Shares or Interests Purchased e. Price Per Share/Total Purchase Price f. Where did this transaction take place? Who was present? g. How did you pay for this investment (i.e., cash, check, money order, wire transfer, etc.)? 6. What were you told that made you decide to invest, such as, the type of profits you might receive, how risky or safe the investment would be, information about the future value of your investment, etc.? Who told you this? 7. What were you told about how the company was going to use your funds? 8. Did you make the company/salesperson aware of your financial situation, investment objectives, and/or your risk tolerance? If so, what was said, to whom, and when? 9. How frequently were you in contact with the company/your salesperson? With whom were you in contact and what did you discuss? American LegalNet, Inc. www.USCourtForms.com 10. 3 Were you encouraged to invest more money in the same or similar investment? If so, what was said to you, by whom, and when? 11. Specifically, describe your complaint: 12. Keeping in mind that the Division connot recover money on your behalf, how would you like your complaint to be resolved ? Please be specific. 13. Describe any contacts you have had with the company/your salesperson concerning your complaint? Please forward copies of any correspondence and other documents between you and the company/your salesperson. 14. Have you contacted any other agency regarding your complaint? If so, please furnish the name of the agency, when filed, and status (if known). American LegalNet, Inc. www.USCourtForms.com 15. 4 Have you contacted a private attorney about this matter? name, address, and telephone number. 16. If you are aware of anyone else who has made a similar investment, please provide names and addresses. 17. Briefly describe your investment experience with respect to this particular investment. Please include the attorney's Documentary evidence is especially important. Please forward copies, not originals, of the front and back of your canceled checks, confirmations, statements, correspondence, certificates, prospectus, and any other written materials pertaining to your complaint. If you need more space, please feel free to forward additional pages. Return your documents and completed complaint form to: Ohio Division of Securities 77 South High Street, 22nd Floor Columbus, Ohio 43215-6131 ATTN: Enforcement Your complaint will remain confidential under R.C. 1707.12. It is a criminal offense and a violation of R.C. 2921.13(A) to make a false statement for the purpose of misleading a public official. Signature Date American LegalNet, Inc. www.USCourtForms.com