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First Name

Last Name

Email Address

Phone Number

Cell Phone Number

Street Address

City

State
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Zip Code

Number of Shares Purchased

Date(s) Shares were purchased

Were shares sold?

If yes, date(s) shares sold

Was your loss on Bear Stears stock:
Under $10,000
Between $10,000 and $100,000
Greater than $100,000

If you know the exact amount of you loss, please provide below

Name of brokerage firm where shares were purchased

Other Comments:

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