Form 08-115a - Complaint Form - State Of Alaska Division Of Banking And Securities Page 5

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5. How and when did you first learn about the investment identified in item 3?
6. Locations(s) where the transaction(s) took place:
7. Was anyone else present with you at the time of the transaction(s)?
No
Yes
If "Yes", please provide their name(s), address, and phone number:
8. Amount of money involved in this transaction(s):
9. Did you sign or receive any documents?
Yes
No
(If "Yes," please attach copies of the documents)
10. Have you complained to the firm(s) or individual(s)?
Yes
No
If "Yes," when and to whom did you talk with?
11. Have you contacted any other governmental or regulatory agency?
Yes
No
If "Yes," please provide the name, address and phone number of the agency, and the name of the
person handling your complaint.
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