John Smith

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 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. I have also included my Uniform Submission Agreement.

My name is John Smith and I live in Los Angeles County, California. I am bringing this claim against Respondent William Jones, a registered representative employed by Respondent XYZ Brokerage Company.

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

I opened my account with XYZ in 1991. Mr. Jones has been my account executive since the account was opened.

In December, 1996, I received word that warrants I owned for HIJ Corporation stock were to be the subject of a tender offer at $5.00 per share. (A copy of the tender notice is attached as Exhibit A.) I held 2,000 warrants at the time. Proof of ownership, in the form of my XYZ statement for December 1996, is attached as Exhibit B.

Since my warrants were being held by XYZ, I instructed Mr. Jones to tender the warrants on the date indicated, since after that date, my warrants would expire. Mr. Jones assured me that my instructions would be carried out. After our telephone conversation, I followed up on my verbal instructions with a faxed message, a copy of which is attached as Exhibit C.

The day after the tender offer expired, I received a call from Mr. Jones indicating that the warrants had not been tendered, and had expired worthless. Mr. Jones apologized to me, but told me that there was nothing he could do. He asked me not to report the incident to his manager, because "it would get me fired and then I couldn't help you get the money back."

I called Mr. Jones's branch manager to discuss the problem, but I never received a response.

At the time I instructed Mr. Jones to tender the warrants, he assured me that he would do so. To confirm our conversation, I sent him a faxed message. Mr. Jones agreed to tender the warrants and assumed responsibility for doing so. He had an obligation to use reasonable care to make sure that the instructions were properly followed, which he failed to do. Mr. Jones' failure to tender the warrants as instructed resulted in a $10,000 loss to me.

I request that the arbitrator finds that I am entitled to reimbursement of the $10,000 plus interest from the date the warrants should have been tendered. I also request that all fees associated with this arbitration plus punitive damages be assessed against Mr. Jones and XYZ Corporation.

I request that this matter be decided by a single arbitrator as a simplified arbitration, without a hearing.

Respectfully submitted,

John Smith