Investor Statement Form - State Of Illinos Page 3

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What, if any, action has been taken?
Have you obtained private legal counsel?
❏ Yes
❏ No
If yes, indicate Name, Business Address and Telephone Number of Attorney:
ATTACH COPIES OF ANY DOCUMENTS REGARDING THIS MATTER. (Include the front and back of all cancelled checks, or other evidences of
payment of the Business Broker’s fee.)
Are you willing to be interviewed by a Securities Department investigator?
❏ Yes
❏ No
Are you willing to testify if formal proceedings are commenced?
❏ Yes
❏ No
DESCRIBE IN DETAIL ANY OTHER INFORMATION THAT MAY HELP THE SECURITIES DEPARTMENT UNDERSTAND THE AGREEMENT AND ANY
DISCUSSION BETWEEN YOU AND THE BUSINESS BROKER. IF MORE SPACE IS NEEDED, PLEASE ATTACH ADDITIONAL SHEETS:
Signature of Borrower
Date
Printed by authority of the State of Illinois. May 2005 — 100 — SEC 318

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