Complaint Form - Arizona Corporation Commission (Page 4 of 5) in pdf

Complaint Form - Arizona Corporation Commission Page 4

Did you begin any legal action against this company?

Yes

Explain:

Are you willing to sign an affidavit or testify regarding your transaction with this company?

Yes

Other governmental or regulatory agencies you have contacted:

May we send a copy of your complaint to another governmental agency or regulatory body for their review

or investigation?

Yes

Did you tape-record any of your conversations regarding the transaction?

Yes

Names, telephone numbers and/or addresses of any other known investors:

Please explain the entire circumstances surrounding your complaint in the space provided below. If you

need more space, attach another sheet of paper.

It is important to include all details about the

transaction, no matter how unimportant you may think they are. Please be specific in referring to any

names, dates or documents. Also, if any part of the transaction occurred outside of Arizona, please

indicate that fact. Remember that it is better to include too much information, rather than too little

information. Be sure to describe the type of investment and any instruments you received evidencing

your investment.

The above is true and accurate to the best of my knowledge.

Signature

Date:

Return completed form to:

Securities Division

Arizona Corporation Commission

1300 West Washington, 3rd Floor

Phoenix, Arizona 85007

REV. 1/13/04

Complaint Form - Arizona Corporation Commission Page 4