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Please fill out this form or download the PDF and fax it in.

Name:

What was the amount of your loss?

Where did the lost investment funds originate?

Are you currently in a posistion that requires you to still pay taxes?

What is your Federal tax filing status?

What is your current taxable income (net after standard deductions)?

Do you currently have any brokerage accounts at this time, if so with whom?

In what name or names was this investment(s) made?

Was your investment to help supplement your current income, retirement or college fund?

How did you originally hear about this investment(s)?

Whom did you speak with directly about this investment(s)?

Name:

When did you first meet with him or her?

How did this person portray him or her self, (owner/broker/salesperson)?

Did you feel pressured to purchase this investment(s)?

Did they provide you a prospectus?

Did you receive monthly or quarterly investment statements?

Did you receive a 1099 on a yearly basis?

What type of promise(s) did he/she give you (returns/guarantees/safe investment/can't lose)?

How much did you first invest, how much principal and how many times did you invest in total? (Please indicate years, if known)

Did he/she have you liquidate in order to become involved in this investment(s)?

Have you ever invested in this type of investment(s) before?

On a scale of 1 to 10, where would you have placed your investment knowledge / skill?

What type of investments did you request, high risk, medium risk or low risk?

At what point did you know that something was not correct and how did you hear of that information?

Did you ever make contact with him or her after hearing this information? If so what happened?

Have you gotten any of your investment back, if so how much?

Where did the lost investment funds originate?

Are you currently in a position that requires you to still pay taxes?

What have you done to recover any of your investment?

Did they follow your instructions with your money; (did he/she use this money for personal gain)?

Is there any other important information you feel I need would need or want to know?

How you prefer to be contacted?

Telephone:

E-Mail:

Best Time to be Reached

I confirm that the above information is accurate and true to the best of my knowledge.

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