ProphetMax Receivership

Claim Form

NOW ACTIVE!

THE DEADLINE TO SUBMIT THIS FORM IS OCTOBER 27, 2015

INSTRUCTIONS


1. You are eligible to submit this form if you have incurred a loss as a result of your investment with Investment Intelligence Corporation d/b/a ProphetMax Managed FX.  This includes membership fees.
2. Please fill out this form completely. Additional information will be requested if this form is incomplete or otherwise insufficient to process your claim. You must respond to any request for additional information; if you fail to respond, your claim may not be processed.
3. You must submit documents to support your claim. Types of acceptable documents may include, but are not limited to, bank statements; wire transfer receipts; emails or correspondence from any of the defendants acknowledging receipt of funds; correspondence from financial institutions referencing the investment; or, any other documents supporting your claim.
4. This form requires you to specifically identify any and all amounts invested, any and all amounts paid as membership fees, as well as any and all amounts charged back or returned to you. The documents you submit should reference any monies returned.
5. While we prefer electronic documents for more efficient processing, you may also submit your claim by mailing your form and documents to: Keri Anderson, Hohmann, Brophy & Shelton, PLLC 210 Barton Springs Rd,Suite 250, Austin, Texas 78704.
6. We will acknowledge receipt of your claim form and documentation via email. You should be aware that it will take time to fully process all of the claims, and the work will be done as promptly as time permits.
7. A "Claim Determination" will be sent via email outlining amount of claim accepted, if any, for membership and investment amounts paid.
8. Any "Claim Determination may be objected to by emailing the Receiver (receiver@prophetmaxreceivership.com) on or before 11:59 p.m. (Central time) 60 days after the Bar Date.
9. We will continue to keep you updated through the Receiver's Facebook site and through the Receiver's website (www.prophetmaxreceivership.com).
10. If any of your contact information changes, please notify us immediately.

 I. Contact Information

 
First Name: *
Last Name: *
Address Street 1: *
Address Street 2:
City: *
State: *
 Country:
Zip Code/Post Code: *  
Daytime Phone: *
Evening Phone:
EMAIL: *
If Claimant is other than an individual, state the name of the entity on whose behalf you are making the claim and the name and capacity of the person completing this form (e.g. Officer, Director, Partner, etc.)*:

*IF YOU ARE SUBMITTING A CLAIM ON BEHALF OF AN ENTITY, PLEASE DO NOT SUBMIT A DUPLICATE CLAIM INDIVIDUALLY. THIS WILL DELAY PROCESSING OF YOUR CLAIM.
 II. Claim Information

 
   
1. Did you invest or pay any membership fee? : *
2. If yes to #1, which ProphetMax program did you join?:  
3. If yes to #1, how much did you pay in membership fees only? Please respond in USD.:
4. Did you invest any other monies?: *
 
5. If yes to #4, how much money did you invest? Please respond in USD.:
6. How much money, if any, was charged back or returned to you?:
 
7. What currency did you invest with?:*
 
 
   
 III. Claim Documentation

 
Identify the type(s) of documentation you are submitting to support your claim and attach to this form (you will be directed to a page to upload your documents after you hit submit): *
   
IV. Acknowledgment of Claimant

By submitting this form, Claimant acknowledges that they have read and agree to submit to the exclusive jurisdiction of the U.S. District Court for the Western District of Texas for all purposes associated with this Claim.
Claimant represents and warrants that the information contained herein is true, accurate and correct. Claimant specifically warrants that Claimant is the rightful and only owner or assignee of the claim submitted.

  Acknowledgment of Claimant (Please check to show you have acknowledged the above).

 
 V. Certification
By signing this form, Claimant certifies that the information is true and correct to the best of their knowledge and belief.
 Electronic Signature (Please affix your signature to this document by typing your name. A typed name will have the full force and effect of a handwritten signature along with the Acknowledgement checked herein): *  
 Date: *  
 Electronic Signature::  
 Date:  
   

Once you hit submit you will be directed to the next step of uploading your claim documentation. Please note: If you do not upload your documentation your claim will not be processed.  ALL investors are required to submit this Claim Form and supporting documentation electronically through the Receiver's website. If you believe you require an alternative method to submit your claim, you may contact the Receiver at receiver@prophetmaxreceivership.com or by letter postmarked no later than [30 days after Bar Date as ordered by the Court] addressed to: ProphetMax Receivership, c/o Guy Hohmann, 210 Barton Springs Rd., Suite 250, Austin, TX 78704 to request approval of the alternative method.


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