(INVESTMENT CONTRACT)
STATE OF INDIANA ) IN THE CIRCUIT/SUPERIOR COURT NO
)SS 2004 TERM
COUNTY OF ) CAUSE NO.----------------FC-
STATE OF INDIANA ) INFORMATION FOR:
) OFFER OR SALE OF AN
vs. ) UNREGISTERED SECURITY,
) IC 23-2-1-3, CLASS C
DEFENDANT’S NAME ) FELONY
(Name of Affiant), being duly sworn says that he/she is a(n) employed
by the Indiana Secretary of State, Securities Division. Upon information and belief, on or about
(date), in COUNTY, STATE OF INDIANA, DEFENDANT’S NAME did
knowingly offer or sell a security that was not registered, was not exempt under section 2 (IC 23-
2-1-2) of the Indiana Securities Act, or was not a federal covered security, as defined in IC 23-2-
1-1(s). To-wit, DEFENDANT’S NAME offered or sold an investment contract, that was not
registered with the Indiana Secretary of State, Securities Division, as required by law. Said
investment contract was offered by DEFENDANT’S NAME (describe nature of the investment)
for the sum of Dollars ($ . ), and/or was sold to (VICTIM’S NAME).
Said offer or sale took place in County, State of Indiana, contrary to the form of the
statutes in such cases made and provided by IC 23-2-1-3 and IC 23-2-1-18.1.
I swear or affirm under penalties for perjury, as specified in IC 35-34-1-2.4, that the foregoing
representations are true to the best of my knowledge and belief, this (Date).
(AFFIANT’S NAME)
PROSECUTOR’S NAME, ATTY NO:
Attorney for the State of Indiana
Judicial Circuit of Indiana
ADDRESS
(OTHER SECURITY)
STATE OF INDIANA ) IN THE CIRCUIT/SUPERIOR COURT NO
)SS 2004 TERM
COUNTY OF ) CAUSE NO.----------------FC-
STATE OF INDIANA ) INFORMATION FOR:
) OFFER OR SALE OF AN
vs. ) UNREGISTERED SECURITY,
) IC 23-2-1-3, CLASS C
DEFENDANT’S NAME ) FELONY
(Name of Affiant), being duly sworn says that he/she is a(n) employed
by the Indiana Secretary of State, Securities Division. Upon information and belief, on or about
(date), in COUNTY, STATE OF INDIANA, DEFENDANT’S NAME did
knowingly offer or sell a security that was not registered, was not exempt under section 2 (IC 23-
2-1-2) of the Indiana Securities Act, or was not a federal covered security, as defined in IC 23-2-
1-1(s). To-wit, DEFENDANT’S NAME offered or sold a(n) DESCRIPTION OF SECURITY,
that was not registered with the Indiana Secretary of State, Securities Division, as required by
law. Said DESCRIPTION OF SECURITY was offered or sold by DEFENDANT’S NAME
(describe nature of the TRANSACTION) for the sum of Dollars ($ . ), to
(VICTIM’S NAME).
Said offer or sale took place in County, State of Indiana, contrary to the form of the
statutes in such cases made and provided by IC 23-2-1-3 and IC 23-2-1-18.1.
I swear or affirm under penalties for perjury, as specified in IC 35-34-1-2.4, that the foregoing
representations are true to the best of my knowledge and belief, this (Date).
(AFFIANT’S NAME)
PROSECUTOR’S NAME, ATTY NO:
Attorney for the State of Indiana
Judicial Circuit of Indiana
ADDRESS
(NOTE)
STATE OF INDIANA ) IN THE CIRCUIT/SUPERIOR COURT NO
)SS 2004 TERM
COUNTY OF ) CAUSE NO.----------------FC-
STATE OF INDIANA ) INFORMATION FOR:
) OFFER OR SALE OF AN
vs. ) UNREGISTERED SECURITY,
) IC 23-2-1-3, CLASS C
DEFENDANT’S NAME ) FELONY
(Name of Affiant), being duly sworn says that he/she is a(n) employed
by the Indiana Secretary of State, Securities Division. Upon information and belief, on or about
(date), in COUNTY, STATE OF INDIANA, DEFENDANT’S NAME did
knowingly offer or sell a security that was not registered, was not exempt under section 2 (IC 23-
2-1-2) of the Indiana Securities Act, or was not a federal covered security, as defined in IC 23-2-
1-1(s). To-wit, DEFENDANT’S NAME offered or sold a promissory note, that was not
registered with the Indiana Secretary of State, Securities Division, as required by law. Said
promissory note was offered by DEFENDANT’S NAME through (NAME OF ENTITY) (if
applicable) for (OTHER ENTITY) (if applicable), had a face value of
(AMOUNT)DOLLARS($0.00), and/or was sold to (VICTIM) for the principal amount of
(AMOUNT) DOLLARS ($0.00).
Said offer or sale took place in COUNTY, STATE OF INDIANA, contrary to the
form of the statutes in such cases made and provided by IC 23-2-1-3 and IC 23-2-1-18.1.
I swear or affirm under penalties for perjury, as specified in IC 35-34-1-2.4, that the foregoing
representations are true to the best of my knowledge and belief, this (DATE).
(AFFIANT’S NAME)
PROSECUTOR’S NAME, ATTY NO:
Attorney for the State of Indiana
Judicial Circuit of Indiana
ADDRESS
(UNREGISTERED BROKER-DEALER OR AGENT)
STATE OF INDIANA ) IN THE CIRCUIT/SUPERIOR COURT NO
)SS 2004 TERM
COUNTY OF ) CAUSE NO.----------------FC-
STATE OF INDIANA ) INFORMATION FOR:
) TRANSACTING BUSINESS
vs. ) BY AN UNREGISTERED, BROKER-
) DEALER OR AGENT, IC 23-2-1-
DEFENDANT’S NAME ) 8, CLASS C FELONY
(Name of Affiant), being duly sworn says that he/she is a(n) employed
by the Indiana Secretary of State, Securities Division. Upon information and belief, on or about
(date), in COUNTY, STATE OF INDIANA, DEFENDANT’S NAME did
knowingly transact business as a broker-dealer or agent as defined in IC 23-2-1-1(c) without
being registered with the Indiana Securities Division as required by law. To-wit,
DEFENDANT’S NAME did transact business as a broker-dealer or agent in Indiana by
offering and/or selling a promissory note for COMPANY NAME to VICTIM NAME for the
principal amount of DOLLARS ($ ) as an agent of COMPANY
NAME, without being registered with the Indiana Securities Division.
Said offer or sale taking place in County, State of Indiana, contrary to the form of the
statutes in such cases made and provided by Ind. Code 23-2-1-8 and Ind. Code 23-2-1-18.1.
I swear or affirm under penalties for perjury, as specified in IC 35-34-1-2.4, that the foregoing
representations are true to the best of my knowledge and belief, this (Date).
(AFFIANT’S NAME)
PROSECUTOR’S NAME, ATTY NO:
Attorney for the State of Indiana
Judicial Circuit of Indiana
ADDRESS
(UNREGISTERED INVESTMENT ADVISOR
OR INVESTMENT ADVISOR REPRESENTATIVE)
STATE OF INDIANA ) IN THE CIRCUIT/SUPERIOR COURT NO
)SS 2004 TERM
COUNTY OF ) CAUSE NO.----------------FC-
STATE OF INDIANA ) INFORMATION FOR:
) TRANSACTING BUSINESS BY AN
) UNREGISTERED INVESTMENT
vs. ) ADVISOR OR INVESTMENT
) ADVISOR REPRESENTATIVE,
) IC 23-2-1-8, CLASS C
DEFENDANT’S NAME ) FELONY
(Name of Affiant), being duly sworn says that he/she is a(n) employed
by the Indiana Secretary of State, Securities Division. Upon information and belief, on or about
(date), in COUNTY, STATE OF INDIANA, DEFENDANT’S NAME did
knowingly transact business as an investment advisor or investment advisor representative as
defined in IC 23-2-1-1(n) without being registered with the Indiana Securities Division as
required by law. To-wit, DEFENDANT’S NAME did transact business as an investment advisor
or investment advisor representative in Indiana (describe with particularity how the person held
himself out as investment advisor or representative as defined in IC 23-2-1-1(n)) naming the
VICTIM(S), if any, without being registered with the Indiana Securities Division.
The transaction of the business of investment advising having taken place in
County, State of Indiana, contrary to the form of the statutes in such cases made and provided by
Ind. Code 23-2-1-8 and Ind. Code 23-2-1-18.1.
I swear or affirm under penalties for perjury, as specified in IC 35-34-1-2.4, that the foregoing
representations are true to the best of my knowledge and belief, this (Date).
(AFFIANT’S NAME)
PROSECUTOR’S NAME, ATTY NO:
Attorney for the State of Indiana
Judicial Circuit of Indiana
ADDRESS
(FRAUD)
STATE OF INDIANA ) IN THE CIRCUIT/SUPERIOR COURT NO
)SS 2004 TERM
COUNTY OF ) CAUSE NO.----------------FC-
STATE OF INDIANA ) INFORMATION FOR:
) FRAUDLENT OR DECEITFUL ACTS
vs. ) WITH THE OFFER, SALE OR
) PURCHASE OF A SECURITY,
) IC 23-2-1-12, A CLASS C
DEFENDANT’S NAME ) FELONY
(Name of Affiant), being duly sworn says that he/she is a(n) employed
by the Indiana Secretary of State, Securities Division. Upon information and belief, on or about
(date), in COUNTY, STATE OF INDIANA, DEFENDANT’S NAME, directly or
indirectly, employed a scheme to defraud, made untrue statements of a material fact, omitted to
state material facts necessary to make the statements made not misleading, or engaged in an act,
practice or course of business that operated as a fraud or deceit. To-wit, DEFENDANT’S
NAME offered and/or sold a security, a promissory note, to VICTIM, for the principal amount of
DOLLARS ($0.00). Said security was offered or sold (describe with particularity
how the security was sold and who it was sold through, if applicable). During the offer or sale,
DEFENDANT’S NAME omitted to inform VICTIM that this (describe security) was a security
and that it was not registered with the Indiana Secretary of State, Securities Division as required
by law. DEFENDANT’S NAME failed to advise VICTIM that he was not registered as a broker-
dealer, agent, or issuer agent with the Indiana Secretary of State, Securities Division as required
by law. (Describe any further fraudulent activities that your investigation revealed such as the
Defendant failing to inform Victim that he had been convicted of crimes previously, stating with
particularity the place and crimes convicted of, and all other fraudulent claims made or omitted
by the Defendant to induce the sale.)
Said activities having taken place in County, State of Indiana, contrary to the
form of the statutes in such cases made and provided by IC 23-2-1-12 and 23-2-1-18.1.
I swear or affirm under penalties for perjury, as specified in IC 35-34-1-2.4, that the foregoing
representations are true to the best of my knowledge and belief, this (Date).
(AFFIANT’S NAME)
PROSECUTOR’S NAME, ATTY NO:
Attorney for the State of Indiana
Judicial Circuit of Indiana
(UNREGISTERED LOAN BROKER OR AGENT)
STATE OF INDIANA ) IN THE CIRCUIT/SUPERIOR COURT NO
)SS 2004 TERM
COUNTY OF ) CAUSE NO.----------------FD-
STATE OF INDIANA ) INFORMATION FOR:
) UNREGISTERED LOAN BROKER
vs. ) OR AGENT, IC 23-2-5-4,
) CLASS D FELONY
DEFENDANT’S NAME )
(Name of Affiant), being duly sworn says that he/she is a(n) employed
by the Indiana Secretary of State, Securities Division. Upon information and belief, on or about
(date), in COUNTY, STATE OF INDIANA, DEFENDANT’S NAME did
knowingly engage or continue in the loan brokerage business as defined in IC 23-2-5-1(f))
without applying to the Commissioner of the Indiana Securities Division as required by law. To-
wit, DEFENDANT did solicit VICTIM through COMPANY (if applicable) for the purpose of
procuring a loan from THIRD PARTY NAME. VICTIM was seeking a loan for the purpose of
(describe – financing something, to pay off debt to purchase something). (Recite facts that
investigation revealed concerning the proposed loan including commitment letter and
distribution plan).
Said loan broker activities took place in County, State of Indiana, contrary to the
form of the statutes in such cases made and provided by IC 23-2-5-4 and IC 23-2-5-16.
I swear or affirm under penalties for perjury, as specified in IC 35-34-1-2.4, that the foregoing
representations are true to the best of my knowledge and belief, this (Date).
(AFFIANT’S NAME)
PROSECUTOR’S NAME, ATTY NO:
Attorney for the State of Indiana
Judicial Circuit of Indiana
ADDRESS
(LOAN BROKER FRAUD)
STATE OF INDIANA ) IN THE CIRCUIT/SUPERIOR COURT NO
)SS 2004 TERM
COUNTY OF ) CAUSE NO.----------------FD-
STATE OF INDIANA ) INFORMATION FOR:
) FRAUDLENT OR DECEITFUL ACTS
vs. ) IN CONNECTION WITH A CONTRACT
) FOR THE SERVICES OF A LOAN
) BROKER, IC 23-2-5-20, CLASS D
DEFENDANT’S NAME ) FELONY
(Name of Affiant), being duly sworn says that he/she is a(n) employed
by the Indiana Secretary of State, Securities Division. Upon information and belief, on or about
(date), in COUNTY, STATE OF INDIANA, DEFENDANT’S NAME, directly or
indirectly, employed a scheme to defraud, made untrue statements of a material fact, omitted to
state material facts necessary to make the statements made not misleading, engaged in an act,
practice or course of business that operated as a fraud or deceit, or collected or solicited
consideration that was not a bona fide third party fee, in connection with a loan until the loan had
been closed. To-wit, DEFENDANT attempted to procure a loan for (BORROWERS NAME) to
(purpose of loan) DEFENDANT advised BORROWER that he had a funding source (Name of
proposed funding source, if applicable). Further, (any additional evidence that investigation
revealed regarding the details of the proposed loan). DEFENDANT engaged in fraud and deceit
during the transaction by (describe fraud and receipt revealed by investigation) Further,
DEFENDANT omitted to inform BORROWER of the following material facts: (describe
material facts omitted such as defendant’s criminal history).
Said activities having taken place in County, State of Indiana, contrary to the
form of the statutes in such cases made and provided by IC 23-2-5-20 and 23-2-5-16.
I swear or affirm under penalties for perjury, as specified in IC 35-34-1-2.4, that the foregoing
representations are true to the best of my knowledge and belief, this (Date).
(AFFIANT’S NAME)
PROSECUTOR’S NAME, ATTY NO:
Attorney for the State of Indiana
Judicial Circuit of Indiana
ADDRESS
