For Office Use Only Wyoming Secretary of StateCompliance Division 2020 Carey Avenue, Suite 700 Cheyenne, WY 82002-0020 Ph. 307.777.7370 Fax 307.777.7640 Email: Investing@wyo.gov Investing Complaint Form Please complete and mail or email this form to the Wyoming Compliance Division with any relevant information attached. All information provided is confidential. SECTION 1: Personal Information Name: Date of Birth: Address: Email Address: Phone Number: Investment Experience: SECTION 2: Investment Information Name of Sales Person/Agent: Firm/Company: Firm/Company Address: Type of Investment: Date of Investment: Total Amount of Money Invested: $ Cash/Check/Money Order $ (Other) How did you learn about the investment: (personal visit, phone solicitation, mailing, etc205?) American LegalNet, Inc. www.FormsWorkFlow.com InvestingComplaintForm - Revised 11/2015 Section 3: Complaint Details Summarize your complaint details: Name: Date: Signature American LegalNet, Inc. www.FormsWorkFlow.com