John Smith

1234 Investor Street

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 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 and maintains a branch office in Los Angeles, California. Its address is [This refers to the address of the branch used by the customer ].

Prior to the time I met William Jones, I had invested primarily in conservative mutual funds and blue-chip stocks.

In April, 1996, I received a call from Mr. Jones, whom I had never met. 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 Mr. Jones that I only invested in mutual funds and blue chip stocks because I didn't believe in risky investment strategies. Mr. Jones said he had an investment that would fit my requirements and he recommended purchasing the stock of Wonderful, Inc., a New York Stock Exchange stock. I had heard of the company and thought it would be a good investment so I approved of the purchase.

Over the next several weeks, Mr. Jones called me and made other recommendations. Some of the suggestions he made were for the purchase of blue-chip stocks and some were for companies I had never heard of. I bought some of the blue-chips Mr. Jones recommended but declined to buy some of the over-the-counter stocks he was suggesting because I didn't know anything about them and they were not in keeping with my goal of only buying blue chips and mutual funds. During the first week of June, 1996, Mr. Jones recommended that I buy 2,000 shares of Risk-O Corp. Mr. Jones strongly and repeatedly told me that the stock was "a rocket", and that the price was only going to go up.

I was not familiar with Risk-O, so I asked Mr. Jones to send me some information on the company. Mr. Jones told me that there was no time, that if I didn't buy right now, I would lose out on a great opportunity. I told him that if he could not provide me with the information I had requested, that I had no interest in buying Risk-O.

Several days later, I received a confirmation in the mail showing a 2,000 share purchase of Risk-O, at a cost of $35,000 (Exhibit A). Mr. Jones' commission on this trade was $1,400.

I immediately called Jones to remind him that I had refused to buy Risk-O and told him to reverse the transaction.

XYZ used funds from my cash reserve to pay for the transaction. Mr. Jones also told me that I was already ahead since Risk-O had risen $.375 per share since the date of purchase. (see Exhibit B) [Exhibit B would be a newspaper clipping showing the price of Risk-O had risen since purchase]. I told Mr. Jones again that I had never authorized the trade and to cancel it.

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