Complaint Report (Investor)

State of Washington DEPARTMENT OF FINANCIAL INSTITUTIONS DIVISION OF SECURITIES P.O. Box 41200 Olympia, Washington 98504-1200 Telephone (360) 902-8700 TDD (360) 664-8126 FAX (360) 902-0524 http://www.dfi.wa.gov Consumer Complaint We have found complaints can normally be resolved if the consumer contacts the company directly. If you have not already done so, please contact the company and attempt to resolve the problem. If direct contact is unsuccessful or you are not satisfied with the results, please fill out this form and send it, along with copies of the company's response and any other appropriate documentation, to the Division of Securities. Your complaint will be promptly acknowledged, and you will be notified of the final disposition. Public Records Disclosure Act: The Washington Public Records Act (PRA), RCW 42.56, may require disclosure of a complaint after a file is closed. If you choose, you may keep your identifying information exempt from disclosure under the PRA by checking this box. Please note that this exemption does not necessarily restrict the release of your identifying information pursuant to a court order, subpoena, or during litigation. Your Information: Name: ____________________________________________________________________ Mailing Address: ___________________________________________________________ City: __________________________ State: _____ Zip: ________________________ Telephone: (_____) _______ - _________ Fax Number: (_____) _______ - ________ Email Address: _____________________________________________________________ Your Complaint is Against the Following Business: Business Name: ____________________________________________________________ Address: __________________________________________________________________ City: __________________________ State: _____ Zip: _________________________ Telephone: (_____) _______ - _________ Fax Number: (_____) _______ - _________ Who You Contacted: _________________________________________________________ Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Additional Information: Names, addresses, phone numbers of any other businesses, or persons involved in your complaint. How and when did you first hear about this investment? How much money did you invest? What Dates? What kind of investment(s) did you buy? How did you pay for your investment(s)? (e.g. personal or cashier's check, cash, wire transfer, etc.) What method did you use to deliver the payment? (e.g. in person, mail, fed ex, etc.) How and when did the person first contact you? Please list any courier or postal service used by the person to contact you and when that contact occurred. Have you complained to the person or firm? If yes, please describe. Was your complaint in writing, or did you speak to someone? If in writing, please send a copy of the complaint. If you spoke with a person, who was it and when did it happen? Have you contacted any other regulator or taken any legal action? If yes, please describe. Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Explain Your Complaint in Detail: Please provide a detailed explanation of the facts that led to your complaint. Start at the beginning and continue through to the present. Be sure to include AT LEAST the following information: How, when, and from whom did you first hear about this investment? What verbal and/or written information did you receive about the investment? Did you later find that any of this information was untrue? Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Other Investors: Do you know anyone else who purchased the investment that is the subject of this complaint? If so, please list their names, addresses, and phone numbers. Jurisdiction of the Securities Division: The jurisdiction of the Securities Division generally extends only to issues connected with the initial offer and sale of securities, franchises, business opportunities, and commodities. We may not have jurisdiction if your complaint involves later actions by management that you think are unfair to investors, or in actions by management such as the failure to hold shareholder meetings or provide annual reports. However, you may have civil remedies available to address your complaint, so please consult your attorney. Also, the Division does not have the authority to represent you in civil litigation, which means you must hire your own attorney to recover your investment funds. Declaration: By signing my name below, I declare, under penalty of perjury under the laws of the State of Washington that the information contained in this complaint is true and accurate and the information may be used to further investigate the complaint. ____________________________ Date ______________________________________ Signature Revised: 03/21/2006 Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com