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Stock Fraud Case Inquiry

PERSONAL INFORMATION

First Name:

Last Name:

E-mail Address:

Address:

City:

State:

Zipcode:

Phone:

() - ext.

INVESTMENT LOSSES

How much are your estimated losses?

Date Purchased?

Amount of Initial investment?

Did broker recommend this investment?

Yes
No

If yes, date sold:

BROKERAGE / ADVISOR INFORMATION

Name of Brokerage Company:

Name of Broker:

If yes, what reason(s) did the broker give as to why you should make investment- what representations did broker make?

If no, did you make investment after reading:

Prospectus
Research Report

Newspaper Article
Investment Magazine

INVESTMENT INFORMATION

Name of Mutual Funds (if applicable):

Name of Variable Annuity (if applicable):

Name of Insurance Company and Policy Type (if applicable):

If options, please describe:

If Equity Indexed Annuity, please describe:

If Individual Stocks, please describe:

Other Information:

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