Fill and Sign the Franchise Complaint Form Indiana

FRANCHISE COMPLAINT FORM Name: _____________________________________ Date of Birth: ____/____/____ Address: ____________________________________ Soc. Sec. #: ______ - ____ - ______ _____________________________________ Phone #: (____) ____ - ______ Franchise Information Name Of Franchise: ____________________________________________________________ Address of Franchise: ___________________________________________________________ 1. How did you learn about this franchise opportunity? Check if applicable. _____(a) Newspaper Advertising Name of the newspaper ___________________________ _____________________________________________________________________________ _____(b) Industry Publication Name of the Publication ___________________________ _____________________________________________________________________________ _____(c) Trade Show Name of the Trade Show __________________________ _____________________________________________________________________________ Date of the Trade Show ____________________ Location _____________________________ _____(d) Television/Radio Advertising What Station ______________________________ _____(e) Another Franchisee Name & Location __________________________ ______________________________________________________________________________ 2. Please give a brief description of the franchise. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 3. Did you have a face - to - face meeting with someone representing the franchisor? YES NO What is the name & title of the person who represented the franchisor? _____________________________________________________________________________ When and where was each meeting held and who was present? 1st Meeting Date: ____/____/____ Location: _______________________________________ Who Attended: _______________________________________________________________ _____________________________________________________________________________ 2nd Meeting Date: ____/____/____ Location: _______________________________________ Who Attended: _______________________________________________________________ _____________________________________________________________________________ 4. Were you given a(n): Offering circular YES NO Franchise Agreement to sign YES NO Financial statements YES NO Statement of projected earnings YES NO Indiana addendum to sign YES NO 5. Were you required to make a commitment by a specific date? YES NO If YES, what was the date? ____/____/____ How many days was it from the date of receiving the offering materials to the date of commitment? _____________________________________________________________________________ Was the commitment verbal or were you required to sign a contract? _____________________________________________________________________________ Did you pay an initial franchise fee? YES NO If YES, what was the amount you paid? _____________________________________________ 6. Did the person representing the franchisor tell you or lead you to believe anything that later turned out to be untrue? Explain. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 6a. Did the offering circular lead you to believe anything that later turned out to be untrue? Explain. ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________ 6b. Did the offering circular omit anything that later turned out to be a material fact? Explain. ______________________________________________________________________________ _____________________________________________________________________________ ______________________________________________________________________________ 7. In your opinion, did the franchisor complete all of its obligations before the opening of your franchise as specified in the disclosure document and franchise agreement? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 8. Has the franchisor upheld the on - going commitments of providing goods and services as specified in the franchise agreement and disclosure document? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 9. For goods and services in connection with the operation of the franchise have you been in contact with the franchisor directly, or a regional representative or another franchise? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 10. Was there a mandatory initial training program? YES NO If YES, who attended? __________________________________________________________ _____________________________________________________________________________ When and where did the training take place? _________________________________________ _____________________________________________________________________________ How long did the training program last? ____________________________________________ 11. Please add any additional statements which you believe to be important. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 12. Are you willing to be interviewed by an investigator from our office? YES NO 13. Are you willing to be a witness if proceedings are initiated by the Securities Commissioner? YES NO 14. Please attach copies of the following documents, if possible: Contracts Disclosure Statements Advertising or promotional materials Operations Manual I hereby certify that I have read the information contained in and attached to this complaint and that all information I have given is accurate and complete to the best of my knowledge and belief. I will cooperate with the Division, but I understand that the staff attorneys are not my personal attorneys, and that I may seek private legal counsel on my own behalf. Signature: ____________________________________________________________________ Printed Name: ________________________________________________________________ Date: ___________________________ Mail the completed form, along with any supporting documentation to: Securities Division 302 W. Washington Street Room E - 111 Indianapolis, IN 46204 IN-01973