Illinois Secretary of State
Securities Department
421 E. Capitol Ave., 2nd Floor
Springfield, IL 62701 • 217-782-2256
69 W. Washington St., Ste. 1220
Chicago, IL 60602 • 312-793-3384
800-628-7937
Business Broker
Client Statement
CLIENT INFORMATION:
Name: Age:
Address:
City: State: ZIP:
Home Telephone Number: Work Telephone Number:
Please indicate the most convenient day to be contacted:
Monday
Tuesday
Wednesday
Thursday
Friday
Please indicate the most convenient time and place to be contacted:
Work (indicate time):
Home (indicate time):
Please indicate how you signed a contract with the Business Broker:
as an individual
in the name of a company
Partnership
Corporation
Limited Liability Company
Other
If an individual, do you have a net worth of more than $1 million or income of more than $200,000 including your spouse?
Yes
No
If a company, does it have an asset value of more than $1 million or gross revenues of more than $200,000 or is it 90 percent owned by persons
with assets of more than $1 million or income or gross revenues of more than $200,000?
Yes
No
INQUIRY REFERENCE TO:
Name of Business Broker:
Address:
City: State: ZIP:
Telephone Number: Email/Internet Address:
Printed by authority of the State of Illinois. November 2015 — 100 — SEC 323.2
By completing this statement you will be assisting the Illinois Securities Department with the inquiry of a Business Broker.
The information received will enable the Securities Department to conduct a more accurate inquiry.
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Name, Title/Position (if known), Address, Telephone Number and Email/Internet address (if known) of person you dealt with:
TRANSACTION INFORMATION:
Describe how you contacted or were contacted by the Business Broker:
Did you sign a contract for the Business Broker’s services?
Yes (indicate date you signed the contract):
No
Did you have the contract reviewed by an attorney before signing?
Yes (indicate name and address of attorney):
No
Did the Business Broker provide you a written description of the services to be performed, the circumstances under which the Business
Broker would be entitled to keep or receive a fee, and the business history of the business broker?
Yes (indicate when this was provided to you):
No
MISCELLANEOUS:
Have you filed an inquiry or complaint with the Business Broker, the Better Business Bureau or any other person or governmental agency?
Yes
No
If yes, indicate Name, Address and Telephone Number of Person or Agency, and Date:
What, if any, action has been taken?
Have you obtained private legal counsel?
Yes
No
If yes, indicate Name, Business Address and Telephone Number of Attorney:
ATTACH COPIES OF ANY DOCUMENTS REGARDING THIS MATTER. (Include the front and back of all canceled checks or other evidences of
payment of the Business Broker’s fee.)
Are you willing to be interviewed by a Securities Department investigator?
Yes
No
Are you willing to testify if formal proceedings are commenced?
Yes
No
DESCRIBE IN DETAIL ANY OTHER INFORMATION THAT MAY HELP THE SECURITIES DEPARTMENT UNDERSTAND THE AGREEMENT AND ANY
DISCUSSION BETWEEN YOU AND THE BUSINESS BROKER. IF MORE SPACE IS NEEDED, PLEASE ATTACH ADDITIONAL SHEETS:
Signature of Borrower Date