Illinois > Secretary Of State > Blue Sky > Securities Department > Investigations
Investor Statement - Illinois
| Investor Statement Form. This is a Illinois form and can be used in Investigations Securities Department Blue Sky Secretary Of State . |
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Illinois Secretary of State Securities Department Jefferson Terrace, Ste. 300 A, 300 W. Jefferson St. Investor Statement Springfield, IL 62702 217-782-2256 69 W. Washington St., Ste. 1220 Chicago, IL 60602 312-793-3384 800-628-7937By completing this statement you will be assisting the Illinois Securiti es Department with the inquiry of a Company, Dealervestment Advisor, In, etc. The information received will enable the Securities Department to conduc t a more accurate inquiry. INVESTOR INFORMATION: Name: Age: Address: City: State: ZIP: Home Telephone Number: Work Telephone Number: Please indicate the most convenient day to be contacted: ? Monday ? Tuesday ? Wednesday ? Thursday ? Friday Please indicate the most convenient time and place to be contacted: ? Work (indicate time): ? Home (indicate time): INQUIRY REFERENCE TO: Name (Company, Firm/Dealer, Investment Advisor, Operator, Driller or Individual): Address: City: County: State: ZIP: Name, Title/Position, Address and Telephone Number of first person you dealt with: CONTACT INFORMATION: Did you know the person who contacted you prior to the sale? ? Yes ? No Did the salesperson come to your home? ? Yes ? No Did to go to the firms place of business? ? Yes ? No Did you meet the salesperson away from the firms place of business (such as a convention, your business, restaurant or other location)? ? Yes (indicate other location): ? No American LegalNet, Inc. www.USCourtForms.com Printed by authority of the State of Illinois. May 2005 100 SE C 318 <<<<<<<<<********>>>>>>>>>>>>> 2Did you receive a telephone call from the firm? ? Yes ? No Did you call the firm? ? Yes ? No Did you receive information in the mail? ? Yes ? No Did you respond to a radio, television or newspaper advertisement? ? Yes ? No DESCRIBE SECURITY PURCHASED OR OFFERED: Common Stock Name: Describe PromissoryNotes or Investment Contract: Describe Bonds or Debentures: LimitedPartnership Interests: ? Yes ? No Fractional undivided interest in oil, gas or other mineral leases: ? Yes ? No Describe other types of securities: Number of notes/shares purchased and amount paid: Date of transaction or date agreement was signed: To whom was payment given or sent: How was payment sent (mail, courier, UPS, etc.):FORM OF PAYMENT: ? Cash ? Credit Card ? Loan ? PromissoryNote ? Check (indicate date check was cancelled and check number): ? Other form of payment (please specify): MISCELLANEOUS: Have you filed an inquiry or complaint with the company, firm, dealer or investment advisor? ? Yes ? No If yes, indicate Name, Address and Telephone Number of Person or Agency and Date: American LegalNet, Inc. www.USCourtForms.com Printed by authority of the State of Illinois. May 2005 100 SEC 318 <<<<<<<<<********>>>>>>>>>>>>> 3What, if any, action has been taken? Have you obtained private legal counsel? ? Yes ? No If yes, indicate Name, Business Address and Telephone Number of Attorney: ATTACH COPIES OF ANY DOCUMENTS REGARDING THIS MATTER. (Include the front and back of all cancelled checks, or other evi dences ofpayment of the Business Brokers fee.) Are you willing to be interviewed by a Securities Department investigato r? ? Yes ? No Are you willing to testify if formal proceedings are commenced? ? Yes ? No DESCRIBE IN DETAIL ANY OTHER INFORMATION THAT MAY HELP THE SECURITIES DEPARTMENT UNDERSTAND THE AGREEMENT AND ANY DISCUSSION BETWEEN YOU AND THE BUSINESS BROKER. IF MORE SPACE IS NEEDED, PLEASE ATTACH ADDITIONAL SHEETS: Signature of Borrower Date American LegalNet, Inc. www.USCourtForms.com Printed by authority of the State of Illinois. May 2005 100 SEC 318
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