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Stock Loss/Stock Fraud/Investment Advice
Securities Loss Questionnaire
Law Offices of Michael J. Trevelline
1920 L Street, NW, Suite 601
Washington, DC 20036-5010
202-737-1139/202-775-1118 (fax)
(In order to maintain attorney-client confidentiality, please do not
disclose your responses to others.)
Date:
Account Information:
Name of account in which loss occurred Total amount of loss claimed $
Total value of account $
Name of Brokerage Co.
Address of Branch Office where account was located:
Your Account No.
2ndAccount No.
Please funrish the following names:
Your broker(s)
Broker's assistant(s) (if known)
Branch Manager
Date Account Opened
Closed or transferred
Brokerage Co. where account transferred to and new account No.:
Broker's Name:
Phone: ( )
Investment Profile:
What was your stated objective or objectives?
Safety of principal
Speculation
Tax Sheltered Income
Income
Long-Term Growth
Inflation Hedge
A Quick Profit
Retirement
Education
Other: (specify)
Investment Experience (at time of opening account):
In # of years
Options
Commodities
Mutual funds
Stocks
Real Estate
Limited Partnerships
Bonds
Oil and Gas
Other (specify)
How did you come to open this account?
Seminar
Known Personally
Walk or Phone in
Referral by
Newspaper Ad
Direct mail
Cold Call
Was Power of Attorney granted? [ ] Yes [ ] No
Was it an asset management account? [ ] Yes [ ] No
Was discretionary authority granted? [ ] Yes [ ] No
Account Description: (check all that apply)
Cash
Speculative
Commodity
Margin
Command (VISA, MASTER, etc.)
Option
Other (specify)
Type of Account:
Individual
Joint
Estate
Trust
Corporate
Custodial
IRA/Keogh
Client Information:
Date of Birth
Place
Education High School [ ] College [ ] Graduate School [ ]
Type of Degrees held
Do you hold any special licenses? Yes [ ] No [ ]
If so, what (real estate, etc.)
Employment:
Job Title Employer's Name (state previous if retired)
Business Address Years there
Marital Status
# of Dependents
Social Security or Tax I.D. #
Residence: Rent [ ] Own [ ]
# of years there
Answer the following questions as of date account opened:
Client's stated Annual Income$ Total Liabilities $
Client's stated net worth exclusive of family residence$
Is Client on fixed income? [ ] Yes [ ] No Citizen of U.S.
Estimated Liquid Net Worth $
Name of Spouse
Name of Spouse's employer
Spouse's annual income $
Other Accounts: (List ALL brokerage accounts in which you did business
before and after loss occurred.)
Company
Account #
Date Opened
Date Closed
Account Worth ($)
Name
Before:
After:
Please provide any other information you think would be helpful:
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