**You must complete and return this form on or before March 31, 2001**

My Full Name Is:

(Please print)

(Last)

(First)

(MI)

Social Security Number:

-

-

Home Address:

(Street)

(City)

(St)

(ZIP)

Mailing Address:

(If different from Home)

(Street)

(City)

(St)

(ZIP)

Home PH:(

)

Work PH:

(

)

Cell PH:

(

)

Email:

Other:

The Individual I invested with is:

The Trust/Entity my contract is with is:

My contract is dated:

The total amount of my investment is:

$

(1)

This includes monies you paid by cash, check or wire transfer. Do not include

unearned interest or any rollover/reinvestment amounts.  If you had multiple

investments, make copies of this form and submit a separate claim for each

Investment.

The total I received back from my investment as either a return of

principal or as an interest payment is:

$

(2)

Please provide a breakdown of these returns:

(Use separate paper and attach to claim form if necessary)

Date

Amount

Principal/Interest?

Claim form continued…

Page 2 of 3

The total of any other monies or benefits I received is:

$

(3)

I.E. Override payments, commission fees, referral fees, funds withdrawn, etc.

Please provide a break down of these monies below.

If you received non-monetary returns such as gifts or favors also list those here

and estimate a value for those.

(Use separate paper and attach to claim form if necessary)

Date

Amount

Purpose of Funds

My Total Claim on this Investment is:

$

(4)

Compute this amount by starting with your investment amount (1), subtract interest/principal

payments received (2), & subtract other payments (3). This will be your net claim amount (4).

Does this investment include any money provided by anyone other

than  yourself, such as a partnership or an investment pool?

(Circle one)

YES  /  NO

If YES, please provide name, address, contact phone number, and amount invested:

(Use separate paper and attach to claim form if necessary)

Additional Information:

(Use separate paper and attach to claim form if necessary)

If you are aware of any other investors please feel free to provide them with a copy of this claim form

and/or list them in the additional information section so we can contact them.

Claim form continued…

Page 3 of 3

IMPORTANT:  Please provide copies of these documents along with this claim form:

(Failure to supply any of these documents may result in the disallowance of your claim)

Copy of your joint venture agreement, borrowing agreement or contract.

Proof of your investment amount. (Copy of your checks, cashier checks, money order,

wire transfers, bank statements and/or receipts.)

Proof of any return or monies you received.  (Copy of your checks, cashier checks, money order,

wire transfers, bank statements and/or receipts.)

ALSO:

DO NOT SEND your completed claim form to the court, this will only delay the claim process.

Once we receive your claim form, a postcard will be sent to you confirming receipt of your claim. IF

you DO NOT receive a postcard from us within three weeks of submitting your claim, it is YOUR

RESPONSIBILITY to contact us immediately to correct the problem.  It is strongly recommended that

you keep a copy of the completed claim form for your records.

IT IS YOUR RESPONSIBILITY to advise us of any address or phone changes.

For more information or to monitor the status of the case, please refer to the Receivership Website:

www.secreceiver.com

PLEASE READ: By signing below I declare under penalty and perjury of law that I have a claim in the

amount set forth above and to the best of my knowledge all information provided on this claim form and any

attachments is correct and factual as I know it.

Claimant

(Please sign)

Date

**You must complete and return this form on or before March 31, 2001**

Please return to:

Quilling, Selander, Cummiskey & Lownds, P.C.

Attn: Stephen Tomasky

2001 Bryan St, Ste 1800

Dallas, TX  75201