1234 Investor St.

Los Angeles, CA 90024

(213) 000-0000

Date

National Association of Securities Dealers, Inc.

Arbitration Department

33 Whitehall Street

New York, New York 10004

Re: Statement of Claim and Request for Simplified Arbitration

John Smith, Claimant and

William Jones and XYZ Brokerage Firm, Respondents

Dear Sir or Madam:

Please accept this letter as my Statement of Claim and request for arbitration under the Small Claims rules of the Code of Arbitration Procedure. Also included is my Uniform Submission Agreement.

My name is John Smith and I live in Los Angeles County, California. I am a sixty-seven year old retiree. My annual income, including social security benefits is $35,000. I am bringing this claim against Respondent William Jones, a registered representative employed by Respondent XYZ Brokerage Company.

XYZ Brokerage ("XYZ" ) does business in the State of California as a securities broker-dealer. XYZ maintains a branch office in Los Angeles, California. Its address is [This refers to the address of the branch used by the customer ].

Until I met William Jones, I had always invested in conservative mutual funds and blue chip stocks. In April, 1996, I received a call from Mr. Jones, although I had never met him. Mr. Jones told me that he would like to open an account for me because he "could make me a lot of money in not a lot of time." I told him that the only investments I had ever made were in mutual funds and blue chip stocks. I also told him that I always tried to invest conservatively because at my age, I could not afford to risk losing my money. Mr. Jones recommended that I purchase Wonderful, Inc., a New York Stock Exchange stock. I had heard of the company and, based on what Mr. Jones told me, I thought it would be a good investment so I bought the Wonderful, Inc. Stock.

Over the next several weeks, Mr. Jones kept calling me and made other stock recommendations, some of which I approved and others that I did not approve. On June 1, 1996, Mr. Jones called me and recommended that I buy 1,000 shares of Dumb & Dumber, Inc. ("Dumb"). Mr. Jones told me that XYZ was a market maker in the stock, and he kept telling me that the stock was "a rocket," and that all the people at XYZ knew it was going to go way up in price.

I asked Mr. Jones for information on Dumb because I had never heard of it. Mr. Jones told me that there was no time, and that if I didn't buy immediately, I would lose out on a great opportunity. I told Mr. Jones that I was not comfortable buying a stock that I didn't know anything about, but he told me he and XYZ knew all about it and he would hate to see me lose out on such a great opportunity. I took Mr. Jones at his word since I thought he had my best interests in mind.

Several days later, I received a confirmation in the mail showing a 1,000 share purchase of Dumb, at a cost of $35,000 (Exhibit A). I sent a check to XYZ to pay for the purchase.

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