Form Com4542 - Explanatory Statement/non-Prejudice Statement - Ohio Dept.of Commerce Page 2

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This form, along with the forms given to other investors, will be submitted to the Ohio Division of Securities. They may be
in touch with you concerning our application. Please cooperate with them fully.
(Please Print)
Name:
Date:
Address:
Phone:
(work)
(home)
I know that I have the right to rescind and receive my money back and hereby elect not to have my money
returned to me.
Signatures:
I,
am aware that the sale made to me was in violation of the Ohio
Securities Act or rules.
I,
am aware of my rights to a return on my investment under section 1707.43 of the Ohio
Revised Code.
I,
have read this form and have placed a checkmark in the box which reflects
my wishes.
EOE/ADA SERVICE PROVIDER
FOR TTY USERS DIAL ORS 1-800-750-0750
COM4542

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