Fill and Sign the In Complaint Form

LOAN BROKER COMPLAINT FORM Personal Information: Name: ______________________________________________________________________ Home Address: ___________________________________________________________ Business Address: ___________________________________________________________ Day Phone #: (____) ____ - ______ Evening Phone: (____) ____ - ______ Information About the Transaction: _________________________________________________ ______________________________________________________________________________ Exactly what were you offered or trying to secure? ________________________________________________________________________ ________________________________________________________________________ What firm or company was making the loan offer? (Please include address.) Name: __________________________________________________________________ Address: _______________________________________________________________ Did you sign an agreement with the loan broker? YES NO Did you give the loan broker any money? YES NO Place of Transaction: __________________________________________________ Amount Paid: ________________ To Whom? _____________________________ Amount of Proposed Loan: _______________________________________________ Type of Payment (Circle one) Cash Check Promissory Note Exchange of Property Other ______________ Details of Any Contract: _______________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Have you received the Loan? YES NO If so, when did you receive it? __________________________________ If not, why not? ___________________________________________________ Additional comments about the loan: ________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Information About the Seller: Who offered to secure the loan for you? Name: ________________________________________________________ Address: _____________________________________________________ Phone: (____) ____ - ______ What were you told by the loan broker before you invested? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Did you know anything about the loan broker other than what the loan broker told you? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Did the loan broker tell you or lead you to believe anything that turned out later to be untrue? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Are you willing to be interviewed by an investigator from our office? YES NO Are you willing to be a witness if proceedings are initiated by the Securities Commissioner? YES NO Please attach copies of the following documents, if possible: Receipts Advertisements Canceled checks (front and back) Contracts Any correspondence related to the above Any advertising relating to the above I hereby verify, subject to the penalties of perjury, that I have read the information contained in and attached to this complaint and that all of the information I have given is accurate and complete to the best of my knowledge and belief. I will cooperate with the Division but understand that the staff attorneys are not my personal attorneys and that I may seek private 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-01976