Investor Statement Form - State Of Illinos Page 2

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Did you receive a telephone call from the firm?
❏ Yes
❏ No
Did you call the firm?
❏ Yes
❏ No
Did you receive information in the mail?
❏ Yes
❏ No
Did you respond to a radio, television or newspaper advertisement?
❏ Yes
❏ No
DESCRIBE SECURITY PURCHASED OR OFFERED:
Common Stock Name:
Describe Promissory Notes or Investment Contract:
Describe Bonds or Debentures:
Limited Partnership Interests:
❏ Yes
❏ No
Fractional undivided interest in oil, gas or other mineral leases:
❏ Yes
❏ No
Describe other types of securities:
Number of notes/shares purchased and amount paid:
Date of transaction or date agreement was signed:
To whom was payment given or sent:
How was payment sent (mail, courier, UPS, etc.):
FORM OF PAYMENT:
❏ Cash
❏ Credit Card
❏ Loan
❏ Promissory Note
❏ Check (indicate date check was cancelled and check number):
❏ Other form of payment (please specify):
MISCELLANEOUS:
Have you filed an inquiry or complaint with the company, firm, dealer or investment advisor?
❏ Yes
❏ No
If yes, indicate Name, Address and Telephone Number of Person or Agency and Date:
Printed by authority of the State of Illinois. May 2005 — 100 — SEC 318

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