*** SECURITIES QUESTIONNAIRE TEMPLATE

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Personal Information:

First Name *

Last Name *

Email *

Address

City

State *

Zip

Daytime Phone *

Evening Phone

Are you a current or former employee of XYZ? *

Not an employee

Current Employee

Former Employee

Purchases and Sales:

Use the fields below to indicate dates and amounts for stock purchases or sales. If you have more than 3 purchases or sales to disclose, please indicate additional transactions in the additional information section.

Purchase Date

Number of Shares Purchased

Price per Share

Date Shares Acquired 1

Number Shares Acquired 1

Date Shares Acquired 2

Number Shares Acquired 2

Date Shares Acquired 3

Number Shares Acquired 3

Sales Date

Number of Shares Sold

Price per Share

Date Shares Sold 1

Number Shares Sold 1

Date Shares Sold 2

Number Shares Sold 2

Date Shares Sold 3

Number Shares Sold 3

Additional Information

How did you hear about this case? *

By clicking the submit button, I acknowledge that this form is not intended to and does not establish an attorney-client relationship between myself and Cohen Milstein Sellers & Toll PLLC, and that the submission or receipt of information to the Firm or one of its attorneys via this form, website, e-mail or telephone does not create an attorney-client relationship.*

I agree with this statement

I agree with this statement *

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Contact Information:

Contact Name, Title - test@test.test
Cohen Milstein Sellers & Toll PLLC
1100 New York Avenue, N.W.
Suite 500, West Tower
Washington, D.C. 20005
Tel: (888) 240-0775 or (202) 408-4600
Fax: (202) 408-4699