Questionnaire

Name:___________________________
Address:
(Street) ___________________________
(City)____________________________
(State/Province)______________________
(Country)___________________________
(Zip Code)__________________________

Social Security/Taxpayer ID Number:________________________________
Telephone (include country code and city code, if applicable):
(Home) (_____)_______________________
(Day Time) (_____)_______________________
Email Address: ________________________________

If you invested in any of the entities listed below, or received any payments, including commission payments, through a trust, alternate name or other entity, please provide the name of the trust, alternate name or entity ___________________________________.

Have you hired an attorney to represent you for the purpose of attempting to recover funds you invested? ____________.
If yes, please provide the name, address and phone number of the attorney:
(Name) __________________________________
(Address) __________________________________
__________________________________
__________________________________
(Phone) __________________________________

Please provide the information requested regarding the various investment schemes or bank accounts:

I. Vista

A. Funds Invested As to each investment you made please provide the following information:
Amount invested $________________
Date of each investment _________________
Method of Payment (check, money order, wire transfer, deduction from commissions, etc.)________________

B. Funds Returned to You (attach additional pages if necessary)
List all funds returned to you either as rollover payments; profit payments or return of principal: $_____________________
Dates of each return ______________________

C. Commission Payments (attach additional pages if necessary)
Amount of Commission Payments You Received $_____________________
Date of Payments _______________________

II. Oakleaf

A. Funds Invested As to each investment you made please provide the following information:
Amount invested $_______________________
Date of each investment _______________________
Method of Payment (check, money order, wire transfer, deduction from commissions, etc.) ________________________

B. Funds Returned to You (attach additional pages if necessary)
List all funds returned to you either as rollover payments; profit payments or return of principal: $_____________________
Dates of each return ______________________

C. Commission Payments (attach additional pages if necessary)
Amount of Commission Payments You Received $_____________________
Date of Payments _______________________

III. Rosewood

A. Funds Invested As to each investment you made, please provide the following:
Amount invested $_______________________
Date of each investment _______________________
Method of Payment (check, money order, wire transfer, deduction from commissions, etc.)________________________

B. Funds Returned to You (attach additional pages if necessary)
List all funds returned to you either as rollover payments; profit payments or return of principal: $_____________________
Dates of each return ______________________

C. Commission Payments (attach additional pages if necessary)
Amount of Commission Payments You Received $_____________________
Date of Payments _______________________

IV. Dexia

A. Funds Invested Amount invested $_______________________
Date of investment _______________________
Method of Payment (check, money order, wire transfer, deduction from commissions, etc.)________________________

B. Funds Returned to You (attach additional pages if necessary)
List all funds returned to you either as rollover payments; profit payments or return of principal: $_____________________
Dates of each return ______________________

C. Rosewood Rollover

Did you rollover any portion of your Dexia investment into Rosewood? ____
Amount of funds rolled over into Rosewood $________
Date of rollover ____________

V. Sandpiper

A. Funds Invested
Amount invested $_______________________
Date of investment _______________________
Method of Payment (check, money order, wire transfer, deduction from commissions, etc.) ________________________

B. Funds Returned to You (attach additional pages if necessary)
List all funds returned to you either as rollover payments; profit payments or return of principal: $_____________________
Dates of each return ______________________

VI. The Bridge Fund

A. Funds Invested Amount invested $_______________________
Date of investment _______________________
Method of Payment (check, money order, wire transfer, deduction from commissions, etc.)________________________

B. Funds Returned to You (attach additional pages if necessary)
List all funds returned to you either as rollover payments; profit payments or return of principal: $_____________________
Dates of each return ______________________

VII. Porter and Chase

A. Funds Invested Amount invested $_______________________
Date of investment _______________________
Method of Payment (check, money order, wire transfer, deduction from commissions, etc.)________________________

B. Funds Returned to You (attach additional pages if necessary)
List all funds returned to you either as rollover payments; profit payments or return of principal: $_____________________
Dates of each return ______________________

VIII. Millenium

A. Funds Invested Amount invested $_______________________
Date of investment _______________________
Method of Payment ________________________

B. Funds Returned to You (attach additional pages if necessary)
List all funds returned to you either as rollover payments; profit payments or return of principal $_____________________
Dates of each return ______________________

IX. Private International Development Banc (PIDB) If you opened an account at PIDB, please provide the following information:

Date Account opened _______________________
Account name ____________________________
Account number ___________________________
Total funds deposited into account ____________________
Total funds withdrawn from account ___________________
Current balance in account ____________________________

Please provide copies of all account opening documents and all account statements with this form.

X. Documentation

Have you already provided documentation to the United States Attorney's Office supporting funds invested and received by you? _______________
Have you submitted a completed questionnaire to the United States Attorney's Office regarding these investments? _____________
Please provide the following documents with this form

A. Copies of your payment(s) made by you (front and back of the cancelled checks, copies or wire transfer confirmations from banks, copies of bank statements with wire transfer details, etc.)
B. Copies of payments received by you (checks, wire transfer, bank statements reflecting deposits)
C. Copies of all contracts or agreements relating to your investments.
D. Copies of all certificates reflecting your investments.

XI. Certification I hereby declare under penalty of perjury under the laws of the United States of America that the foregoing information is true and correct.

Dated: ____________________________
Place (County, State and Country): __________________
(Signature) ____________________________________
(Print name) ____________________________________