Fillable Investor Statement Illinois Secretary of State Securities Department (Illinois Secretary of State)

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Investor Statement Illinois Secretary of State Securities Department (Illinois Secretary of State)

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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
Investor Statement
INVESTOR 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):
INQUIRY REFERENCE TO:
Name (Company, Firm/Dealer, Investment Advisor, Operator, Driller or Individual):
Address:
City: County: State: ZIP:
Name, Title/Position, Address and Telephone Number of first person you dealt with:
CONTACT INFORMATION:
Did you know the person who contacted you prior to the sale?
❏ Yes
❏ No
Did the salesperson come to your home?
❏ Yes
❏ No
Did to go to the firm’s place of business?
❏ Yes
❏ No
Did you meet the salesperson away from the firm’s place of business (such as a convention, your business, restaurant or other location)?
❏ Yes (indicate other location):
❏ No
Printed by authority of the State of Illinois. December 2015 — 100 — SEC 318.1
By completing this statement you will be assisting the Illinois Securities Department with the inquiry of a Company, Dealer, Investment Advisor, etc.
The information received will enable the Securities Department to conduct a more accurate inquiry.
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Did you receive a telephone call from the firm?
❏ Yes
❏ No
Did you call the firm?
❏ Yes
❏ No
Did you receive information in the mail?
❏ Yes
❏ No
Did you respond to a radio, television or newspaper advertisement?
❏ Yes
❏ No
DESCRIBE SECURITY PURCHASED OR OFFERED:
Common Stock Name:
Describe Promissory Notes or Investment Contract:
Describe Bonds or Debentures:
Limited Partnership Interests:
❏ Yes
❏ No
Fractional undivided interest in oil, gas or other mineral leases:
❏ Yes
❏ No
Describe other types of securities:
Number of notes/shares purchased and amount paid:
Date of transaction or date agreement was signed:
To whom was payment given or sent: How was payment sent (mail, courier, UPS, etc.):
FORM OF PAYMENT:
❏ Cash
❏ Credit Card
❏ Loan
❏ Promissory Note
❏ Check (indicate date check was canceled and check number):
❏ Other form of payment (please specify):
MISCELLANEOUS:
Have you filed an inquiry or complaint with the company, firm, dealer or investment advisor?
❏ 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
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Investor Statement Illinois Secretary of State Securities Department (Illinois Secretary of State)

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Completed 28 August 2020

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