WORKSHEET

The following information will assist you in bringing all the facts together regarding your case and help you prepare your Statement Of Claim.

Exact Name(s) In Which Accounts Are (were) Held:

Name:

If Account(s) Held In More Than One Name, Describe Relationship Of Account Holders:

Age:

Marital Status: Number of Dependents:

Name of Spouse:

Spouse's Employer:

Spouse's Annual Income:

Education: [ ] High School [ ] College [ ] Graduate

Degrees Held?

Do You Or Your Spouse Hold Any Professional Or Occupational [ ] Yes [ ] No

If So, What Type?

Employment Employer's Name (State Previous If Retired): Years There:

Job Title:

Business Address:

Occupation:

Residence: [ ] Rent [ ] Own Years There [ ]

Answer the Following Questions as of Date Account Opened:

Stated Annual Income Total Liabilities (FROM ALL SOURCES):

Stated Net Worth Exclusive of Family Residence:

Value of Fixed Assets:

Estimated Liquid Net Worth:

Are You on a Fixed Income? [ ] Yes [ ] No

Bank Name / Bank Address:

[ ] Savings [ ] Checking

Investment Experience:

Briefly Describe Your Investment Background and Experience:

# of Years At Time of Opening Account # of Years

[ ] Options [ ] Commodities [ ] Mutual Funds

[ ] Stocks [ ] Real Estate [ ] Limited Partnerships

[ ] Bonds [ ] Oil & Gas [ ] Other

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:

Investment Profile: What Was Your Stated Objective?

[ ] Safety of Principal [ ] Speculation [ ] Additional Risk

Capital $____________________________________

[ ] Tax Sheltered Income [ ] Income

[ ] Long-term Growth [ ] Hedge

Please Furnish the Following Names:

Your Broker Broker's Assistant:

Branch Manager Regional Manager:

Branch Phone:

Date Account Opened / Date Account Transferred:

Brokerage Company Where Account Transferred:

New Account Number:

Broker's Name:

How Did You Come to Open this Account ??

[ ] Seminar [ ] Known Personally

[ ] Walk or Phone in [ ] Referral by

[ ] National Advertising [ ] Local Ad

[ ] Direct Mail Solicitation [ ] Cold Call [ ] Other

Was Power of Attorney Granted? [ ] Yes [ ] No

Was It Discretionary? [ ] Yes [ ] No

Was It An Asset Management Account? [ ] Yes [ ] No

Account Description: (Check All That Apply):

[ ] Cash [ ] Speculative Commodity

[ ] Margin [ ] Command (Visa, Master, Etc.)

[ ] Option [ ] Other (Specify)

Type of Account:

[ ] Individual [ ] Joint Wros

[ ] Trust [ ] Corporation

[ ] Ira/Keogh [ ] Other

Description of Problem:

Total Amount of Loss Claimed:

Total Value of All Assets Deposited into Your Account (Money, Stock, Etc.):

Value as of Today's Date:

How Did You First Meet Your Broker and Where Did Your First Meeting Occur?

What Did He Tell You and How Did He Advise You During Your First Meeting?

What Did You Tell Him Your Goals Were (Investment Objectives)?

Did You Follow His Recommendations? Always [ ] Sometimes [ ] Never [ ]

What Did He Tell You about the Risks Involved?

What Level of Risk Were You Willing to Assume?

How Often Did You Call Your Broker? Phone Records? YES[ ] NO [ ]

How Often Did Your Broker Call You? Was It Long Distance? YES [ ] NO [ ]

How and When Did You First Learn That There Was a Problem in Your Account. Describe Briefly (Cite Date If Available):

What Did You Do After Discovering The Loss/problem?

What Did Your Broker Tell You?

Did You Speak to the Branch Manager?, If So, What Did He Say?

Did You Write Any Letters to the Broker, Manager, or Company? If So, Please Explain (How Many Times, Etc.):

Do You Have Copies?

Why Do You Feel That You Have a Claim Against Your Broker or His Company?

You Could Settle this Case Today, What Would You Be Willing to Take?

Has Your Broker Or The Company Sent You Any Communications, Letters, Wires, Telegrams, Or Other Material Concerning The Investment Or The Loss? If So, Please List Or Gather Together All Such Documents.

Confirmation Slips

Monthly Statements

Annual Statements

New Account Forms

Margin Agreement

Option Agreement

Letter(s) from Broker

Disclosure Statements

Research Reports

Memos

Prospectuses

Discretionary Form

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