Complaint Information Sheet

D WE S T ITE D AN DIV ED WE FA ID E PLURIB US M UNU SALUS PO MDC PUL I SUPREM CCXX JAMES C. KIRKPATRICK STATE INFORMATION CENTER (573) 751-4936 JASON KANDER SECRETARY OF STATE STATE OF MISSOURI Complaint Information Sheet Investor Information Mr. Mrs. Your Name Address City Home Telephone ( Email address ) State Business Telephone ( Other Company and Representative Information Name of Company Address City Telephone ( ) Complaint Information Please provide a brief summary of your complaint in the space provided below. If you feel that additional space is needed, feel free to use the space provided on the back of this form. Please answer the questions on the next page as well; this allows our staff to gather the most pertinent information to aid in our review of your complaint. State Zip Representative ) Zip Ms. Date of Birth LL UN X ESTO LE A DIVISION OF SECURITIES (573) 751-4136 American LegalNet, Inc. www.FormsWorkFlow.com Investment Information 1. Explain what you were offered: 2. How much money did you invest? 3. Date of investment(s): Payment was made by: Place of investment(s): cash check other 4. Please give a brief explanation of how you gained knowledge of this investment and exactly what you were told about the investment. a. What were you told your money would be used for? b. What amount of return were you promised? c. What were you told about the risks of this investment? d. Did you receive a prospectus or other information regarding the financial condition of the company? e. Did the seller give you information that later turned out to be untrue? If yes, please explain: f. Did you sign a contract? 5. Have you contacted an attorney or any other government agency? If yes, who? 6. Have you asked for the return of your initial investment? If so, did you receive it? 7. Please provide the names, addresses, and telephone numbers of anybody else that you know that made the same investment or dealt with the same representative: American LegalNet, Inc. www.FormsWorkFlow.com Document Copies Please attach copies of the following documents: Stock certificates/bonds/investment certificates Confirmations of purchases Cancelled checks (front and back) Contracts Any other documentation or advertising relating to the investment Signature: Printed name: Date: Please be advised that this division is prohibited by law from giving you legal advice, legal opinions, or acting as your private attorney. Therefore, you may wish to consult with a private attorney to discuss your legal rights and remedies. If you have any question about this form, please call the investor hotline at: 1 (800) 721-7996. Please mail all correspondence to: Office of the Secretary of State Securities Division PO Box 1276, 600 W. Main St. Jefferson City, MO 65102 To send your complaint via email: securities@sos.mo.gov (If you file your complaint via the internet or via email, be sure and send the documents requested above.) American LegalNet, Inc. www.FormsWorkFlow.com