UTAH DEPARTMENT OF COMMERCE Division of Securities COMPLAINT FORM Information About This Form and the Utah Division of Securities 1. You may type or print on this form, but please make your responses legible. 2. It's important for you to fill out each block of this form so that we can fully evaluate your complaint. If a particular block doesn't apply to your situation, please indicate so by placing an "N/A" (i.e., not applicable) in the appropriate space. 3. If you need additional space for any of your responses, please use the continuation blocks provided on page 8 of this complaint form. 4. Please attach copies of all documents relevant to your complaint -- for example: cancelled checks (both sides), contracts, correspondence, prospectuses, sales brochures, etc. 5. We will treat your complaint as confidential. However, please be advised that under current Utah law your complaint will be subject to release to members of the public under certain circumstances. If you have any questions about this matter, please contact the Division's Records Officer. 6. When you have completed this form, please mail it (along with any attachments) to: Utah Division of Securities, Box 146760, Salt Lake City, Utah 84114-6760. If you wish to contact the office by phone, our number is: (801) 530-6600. Our FAX number is (801) 530-6980. Our office is open for your inquires Monday through Thursday (except legal holidays), 7:00 a.m. to 6:00 p.m., Mountain Time. 7. Please be advised that the Division will not act as your attorney for purposes of recovering a lost investment. Any person who has lost money as the victim of an unlawful securities transaction should immediately contact his or her personal attorney about the possibility of bringing a lawsuit to recover lost funds. If your case involves a violation of the Utah Uniform Securities Act, Utah Code Annotated § 61-1-1 et seq., as amended, you may be able to bring a civil action under § 61-1-22 of the Act to recover your lost funds (with 12% interest) and reasonable attorney's fees. 1 American LegalNet, Inc. www.FormsWorkflow.com BLOCK A: INFORMATION ABOUT YOU Block A(1) -- Your Name ______________________________________________________________________________ Last Name / First Name / Middle Initial Block A(2) -- Your Home Address ______________________________________________________________________________ Street Address / City and State / Zip Code Block A(3) -- Your Phone Numbers ______________________________________________________________________________ Area Code and Home Phone Number / Area Code and Business Phone Number BLOCK B: INFORMATION ABOUT YOUR INVESTMENT Block B(1) -- Nature of Investment. In your own words, briefly state what kind of an investment you bought or thought you were buying. For example: a stock; a bond; a note; an investment contract; a limited partnership; an oil, gas, or mining title or lease; a commodity contract or commodity option, etc. If you're not sure what kind of security (if any) you were offered, please state so. Please also state how many shares, items, units, etc., you bought or thought you were buying. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2 American LegalNet, Inc. www.FormsWorkflow.com Block B(2) -- Person Making Initial Contact. What is the name, address, and phone number(s) of the person who initially contacted you about your investment? ______________________________________________________________________________ Last Name / First Name / Middle Initial ______________________________________________________________________________ Street Address / City and State / Zip Code ______________________________________________________________________________ Area Code and Home Phone Number / Area Code and Business Phone Number ______________________________________________________________________________ Any Title And/Or Company Name Used By This Person Block B(3) -- Form Of Initial Contact. How were you initially contacted about your investment by the person identified in Block B(2) above? Check one of the following: [ ] By phone [ ] By mail [ ] By telegram [ ] By Fax [ ] In person [ ] Other If Other, explain below: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ________________________________________________________________________________ Block B(4) -- Where Contact Originated. If you were initially contacted by phone, mail, telegram or fax about your investment, by the person identified in Block B(2), do you know from where the message originated? If so, please give this information below. ______________________________________________________________________________ City / State or Province / Country 3 American LegalNet, Inc. www.FormsWorkflow.com Block B(5) -- Date Of Contact. On what date did the person identified in Block B(2) initially contact you? (mm/dd/yy): _____ / _____/ 19_____ Block B(6) -- Place of Contact. Where were you when initially contacted by the person identified in Block B(2) about your investment? Give the location below. ______________________________________________________________________________ City / State or Province / Country Block B(7) -- Payment For Investment. How much did you pay for your investment (if anything) and in what form did you tender payment? Check one of the following. [ ] Cash [ ] Check [ ] Money order [ ] Wire transfer [ ] Trade [ ] Other Amount (in U.S. Dollars): $ ______________ Block B(8) -- To Whom Payment Was Made. To whom did you make payment for your investment? On what date did you make payment? Where was the payment made or sent to (if made by wire transfer or mailed)? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Block B(9) -- Other Contacts. In connection with your investment, have you been contacted by any other person or office? If so, please give specifics below. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 4 American LegalNet, Inc. www.FormsWorkflow.com BLOCK C: WHY YOU'VE MADE A COMPLAINT TO THE DIVISION In the space provided below, please explain why you've made this complaint to the Utah Division of Securities. To help organize your thoughts, answer the following two questions: (1) What was the investment deal you made or thought you made?; and (2) If you think you have been treated unfairly as a result of this deal, why do you feel that way? Please give full details of who, what, when, where, why, and how. Try to write down the exact words of persons identified in Block B(2) and B(9). It's better to give too much detail than too little. Please feel free to continue your response on page 8 of this complaint form, if necessary. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 5 American LegalNet, Inc. www.FormsWorkflow.com BLOCK D: WITNESS(ES) TO YOUR STORY Do you know of any witness(es) who can verify any of the information you've provided in Block C of this complaint? If so, please provide their names, addresses, and phone numbers below. Also indicate what information they can provide to the Division and whether they were present when the person(s) identified in Blocks B(2) and B(9) spoke with you about your investment. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ BLOCK E: OTHER VICTIMS. Do you know of any others who have been victimized in an investment transaction involving persons identified in Blocks B(2) and B(9) of this complaint? If so, please give their names, address, and telephone numbers below. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _________________________________________________________________________________ 6 American LegalNet, Inc. www.FormsWorkflow.com BLOCK F: SELF-HELP Block F(1) -- Complaints To Other Agencies. In connection with the subject matter of this complaint, have you contacted any other state or federal agency? If so, please give this information below. ______________________________________________________________________________ Agency Name / Person Contacted / Phone Number Block F(2) -- Private Legal Action. In connection with the subject matter of this complaint, have you commenced a lawsuit against any person? If so, please give this information below. ______________________________________________________________________________ Defendant's Full Name / Court Where Filed / Docket Number ______________________________________________________________________________ Your Attorney's Name / Law Office Phone Number Certification BY SIGNING BELOW, I certify that the information I've provided in this complaint is true to the best of my knowledge. If the Division of Securities determines that the subject matter of this complaint is more appropriately within the jurisdiction of another agency of the State of Utah, or an agency of the U.S. Government, I hereby grant permission to the Division to forward this complaint to that agency for any action it deems appropriate. __________________________________________________ Complainant's Signature / Date [ Continuation blocks are provided on the reverse side of this page ] 7 American LegalNet, Inc. www.FormsWorkflow.com Continuation Blocks The following is a continuation of Block __________: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ The following is a continuation of Block __________: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 8 American LegalNet, Inc. www.FormsWorkflow.com