INSTRUCTIONS
THISQUESTIONNAIRE IS FOR INFORMATION PURPOSES SO WE CAN LEARN ABOUT YOU AND YOUR CLAIM. IT IS IMPORTANT IT BE COMPLETED EVEN IF RESPONSES ARE BASED UPON ESTIMATES, APPROXIMATE AMOUNTS, OR APPROXIMATE DATES IN TIME TO THE BEST OF YOUR KNOWLEDGE AND INFORMATION. This Questionnaire is for evaluative purposes to determ ine whether to undertake your representation in a potential leg al m atter. The Inform ation you provide to us isfor the purpose ofseeking leg al representation and is confidential and privileg ed. Responding or com pleting this Questionnaire shallnot create an Attorney-Client relationship which can only be established after all potential conflicts of interest can developed, after careful consideration of the relevant facts that m ay pertain to your claim or claim s, and a written fee ag reem ent is entered into between us setting forth, am ong other things, the scope of our representation. All claim s arising under state or federal law have deadlines, are tim e sensitive and willbe forever barred or lost if not brought within a specified period oftim e after these events occurred or should have been discovered. Unless, and until, representation is offered to you by way ofa written fee ag reem entform ally undertaking yourrepresentation in this m atter,we shallnotbe responsible should your putative claim not be broug ht in a tim ely m anner, or isforever barred or lost, as a result of the applicable statutes of lim itation relating to your claim . The evaluation of your claim ,any tentative conclusions about any claim , should not construed or be relied upon as an opinion or determ ination as to the viability or non viability of any such claim , nor shall be construed or relied upon in any as investm ent advice in deciding to buy, sell or hold any security which m ay be subject to any such claim .
I. Client Contact Information
Your Name: ____________________________________________ Address: ____________________________________________
Home Telephone Number: ________________________________ Work Telephone Number: ________________________________ Cellular/Wireless Number: ________________________________ E-mail Address: ________________________________
II. Introductory and Background Information
Name of Brokerage Firm(s)(Against Whom You Have This Claim):
Name of Your Broker (Against Whom You Have This Claim):
Branch Office Address: __________________________________________ Names On Account(s): __________________________________________ Dates Accounts Opened: __________________________________________
Date(s) of Birth of Account Owners: 1. ___________ 2. ___________ Education
| Highschool: College: College: | Year: Year Year | Location: Major/degree Major/degree | ||||||
|---|---|---|---|---|---|---|---|---|
| Family: | (Spouse): (Children): | Age(s): Age(s): | ||||||
| Occupational History: Employer | Title/Position | Years | ||||||
| Customer Owned Business(es): Name Location | Description | Years | ||||||
Prior Investment Experience: Name/Investment Firm
Approx. Years of Account Value Accounts
| Years of Account | Approx. Value Accounts | ||
| a. | Equities: | ||
| b. | Bonds: | ||
| c. | Options: | ||
| d. | Margin: | ||
| e. | Mutual Funds: | ||
| f. | Annuities: | ||
| g. | Other Fixed Income: | ||
| h. | Partnerships/Real Estate | ||
| j. | Other (Please specify): |
The Reason For The Decision To Invest: _____________________________ Approximate Value Initial/Total Investment: Source of Investment: How and Why Was This Brokerage Firm and Broker Chosen: _______________ Other Brokerage Accounts (Held At The Time This Account Was Opened):
What level of investment risk were you willing to assume?
| None | Minimal | Moderate | Substantial | High |
| What was your primary investment objective: Safety Income Moderate | Growth | Aggressive | ||
| At The Time The Investment Was Made List The Following: | ||||
Your Age:________ Employment:________ Income: _________ Investable Assets: ________ Total Savings: ________
Date Of First Contact With Broker/Brokerage Firm:______________________
What Did You Tell Your Broker About Your Investment Objectives, Knowledge of Investments, or Level of Risk You Were Willing To Take:
What specific information did you tell your broker that you wanted to accomplish or do through your investing?
Where was the money held prior to being invested in this account?
Did you have specific ideas on the way you wanted to have your money invested and/or the stocks (other) in which you wanted to invest?
E. INVESTOR INFORMATION
Have you ever attended any investment related seminars (if so, when)?
Have You Held Any Professional Licenses:
Are you a member of any class action lawsuit related to any of the investments of which you complain?
Yes No
Please list any lawsuits and the nature of any lawsuit to which you have been a party as plaintiff or defendant
Have you ever been charged or convicted of any felony, or misdemeanor? (If so, please explain).
Do you subscribe to any internet related investment services?
Have you ever served on the Board of Directors of Any Public or Private Company?
Have you ever posted on any blog or bulletin board or downloaded financial or investment information from the Internet
Please list any financial or other publications to which you subscribe:
How often did you communicate with the broker and who initiated the contact?
Was contact made by phone or in person?
Did you ever communicate with your broker by e-mail?
Did you ever place transactions on-line, or review your account on-line (if so, how frequently)?
Briefly Summarize Your Complaint, What You Believe The Broker Did That Was Wrong or Unlawful, What The Problem Was, What Caused Your Damages:
Please Estimate To The Best Of Your Ability Your Total Out-Of-Pocket Losses (Not Including Lost Interest Or Lost Income) From The Investments About Which You Complain. “Out-of-Pocket Losses” include the total value of cash or securities deposited into your account, less any withdrawals from the account, less the final balance of cash or securities in the account.
Total Deposits: ____________________
Total Withdrawals: ____________________
Residual or Ending Value: ____________________
| F. | DOCUMENTS | |||
|---|---|---|---|---|
| Did you sign a Customer Agreement: | ||||
| Margin Agreement: | Option Agreement: | |||
| Investment Risk/ Questionnaire: | Other (Please Describe): | |||
Did you Receive: Monthly Account Statements: Completed Account Agreements: Forecasts/Plans/Analysis: Sales Lit./Marketing Brochures: Prospectuses: Subscription Agreements: Correspondence Management: Investment Research Reports: Written Investment
Recommendations: Other Communications (Please Describe):
Do you have copies of the documents you received?
Please tell us anything else that you deem helpful?
BY SIGNING BELOW, I CERTIFY THAT THE FOREGOING INFORMATION IS SUBSTANTIALLY ACCURATE THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF. I UNDERSTAND THAT IF ANY OF THE FOREGOING INFORMATION IS NOT ACCURATE THAT IT MAY HAVE A MATERIAL ADVERSE IMPACT ON THE SUCCESS OF ANY CLAIM I MAY HAVE, AND COULD RESULT IN THE TERMINATION OF ANY FUTURE REPRESENTATION BY YOU.
Dated: _____________ Signature: _________________________
Name: ___________________________
NOTES