State Corporation Commission Division of Securities PO BOX 1197 Richmond, VA 23218 SRF_General@scc.virginia.gov (804) 371-9051 (Phone) (804) 371-9911 (Fax) I wish to file a complaint: (please print) 1. My name is: 2. Home Telephone: Work Telephone: (Area Code + Number) (Area Code + Number) 3. Mailing Address: City: State: Zip: E-Mail Address: 4. I am complaining against: (Name of Firm, Broker, Investment Adviser, Franchisor selling agent) (Address, if known, including city, state and zip code) (Telephone number, if known) 5. How much did you invest and in what form? 6. When and where did the investment(s) take place? 7. Who was payment made payable to? 8. What were you told about the investment prior to investing? 9. Did you receive a prospectus or disclosure document? Yes No 10. How did you learn about the investment opportunity? American LegalNet, Inc. www.FormsWorkflow.com 11. Who contacted and communicated with you about the opportunity and when? 12. Do you know of other investors? If so, please provide their names, phone numbers, and addresses. 13. If you have talked with an attorney, please list their name, phone number, and address. 14. What action, if any, has your attorney taken? *Note: While many firms require their customers to adhere to an arbitration process in lieu of personal court action, no agreement can prohibit you from filing a complaint nor can it prohibit this division from conducting an investigation. The details of my complaint are: (type or print clearly) I am enclosing copies of all correspondence or other papers reasonably available to me relating to this matter that may assist the Division of Securities in its evaluation of my complaint. I understand that this form and any or all of the enclosed information is confidential and is made available only to Commission and enforcement staff involved in the investigation. 5,000 – 9/02 American LegalNet, Inc. www.FormsWorkflow.com