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List All Brokerage Accounts in Which You Did Business Before and After Loss Occurred:

Before:

Company Name:

Account # Opened:

Date Closed:

Account Value:

Profit or (Loss):

After

Company Name:

Account # Opened:

Date Closed:

Account Value:

Profit or (Loss):

Notes:

Account Information:

Name of Account in Which Loss Occurred:

Name of Brokerage Company:

Address of Branch Office:

Account Number 1:

Account Number 2:

Account Number 3: