Complaint Form

COMPLAINT FORM Please type or print in ink only. Send completed complaint form with copies of your relevant documents to the Securities Division. Mail to: E-mail to: Complaints, Securities Division, Arizona Corporation Commission 1300 W. Washington, 3rd Floor, Phoenix, Arizona 85007 SecuritiesDiv@azcc.gov Your Name: __________________________________________________________________________ Your Address: _________________________________________________________________________ City: ____________________________________ State: ________________ Zip: ________________ Home Phone: _____________________________ Business Phone: _____________________________ Cell Phone: _______________________________ E-mail Address: _____________________________ Fax: ______________________________ Preferred means of being contacting? __________________ Name of FIRM and/or PERSON complained of: _____________________________________________ _____________________________________________________________________________________ Address: _____________________________________________________________________________ City: ____________________________________ State: ________________ Zip: ________________ Phone: ______________________________________________________________________________ Name of Stockbroker or Salesperson: ______________________________________________________ _____________________________________________________________________________________ Dates of investment transactions: _________________________________________________________ Place of transaction(s). Specify the states in which you and the salesperson were located at the time of the transaction(s). _____________________________________________________________________________________ Witnesses to the transaction(s): ___________________________________________________________ _____________________________________________________________________________________ 1 American LegalNet, Inc. www.FormsWorkFlow.com Amount of money involved in transaction(s): ________________________________________________ Did you sign any papers or documents? Yes No complaint. If yes, please attach copies of them to this How did you first learn about the investment complained of? ____________________________________ When did you first learn about the investment complained of? __________________________________ Have you complained to the Company or Firm? Yes No If yes, to whom? ________________________________When? ________________________________ What was the response to your complaint to the Company or Firm? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Have you contacted other governmental or regulatory agencies? Yes No If yes, who? ______________________________ Which agency? ______________________________ At what address? ______________________________________________________________________ Please provide the names, telephone numbers, and addresses of other known investors. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 2 American LegalNet, Inc. www.FormsWorkFlow.com Does an attorney represent you regarding the investment complained of? Yes No If yes, provide attorney's name and address: _________________________________________________ _____________________________________________________________________________________ Have you or other victims filed a lawsuit against anyone regarding the investment complained of? Yes No If yes, provide name of court: _______________________________________________ Case number: ______________________________ Date case filed: _____________________________ Attach to this complaint copies of court documents. What were you told about the investment complained of? Which, if any, statements were false? Why do you believe the statements were false? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Did you discuss with anyone your investment objectives and the amount of risk that was acceptable to you regarding the investment complained of? Yes No If yes, please describe specifically to whom you spoke, when, and what you said. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 3 American LegalNet, Inc. www.FormsWorkFlow.com Are you willing to sign an affidavit or testify regarding your transaction? Yes No In the space provided below, please explain the entire circumstances surrounding your complaint. If you need more space, attach another sheet of paper. It is important to include all details about the transaction, no matt