FOR RECEIVER’S USE ONLY

Investor Number ___________

Date Received _____________

In Receivership
BRYCAR FINANCIAL CORPORATION
(“BRYCAR”)

PROOF OF INVESTMENT FORM

** For Use By Investors **

A bar date for claims has not yet been set by the Court for this Receivership. The Receiver
will send to each investor and creditor a Bar Date Order Notice once it has been entered by
the Court. Once the bar date has been set, Proof of Investment Forms received after such date
may be precluded from receiving any distributions of funds by the Receiver.

By signing and returning this Proof of Investment Form, you are certifying, under penalty of
perjury, the truth and accuracy of the information set forth herein.

If the space provided below is insufficient, please feel free to attach additional pages for your
responses.

Name of Investor:

Mailing Address:

City: State: Zip:

Business Phone Number:

Home Phone Number:

Cellular Phone Number:

Facsimile Number:

E-mail Address:
U.S.A. Taxpayer I.D., U.S.A. Social Security Number, or Passport I.D. Number:

Brycar Account Nos.

You must com plete and return this Proof of Investment Form and the
Certification attached hereto as Exhibit “A”
1. List the following information for all money invested by you in the above referenced
investment accounts:

Date (mm/dd/yy) Amount Account Paid to Check No.

2. List the following information for all distributions made to you for the above referenced
investment accounts, and any other payments relating to BryCar investments, including
commissions or referral fees:

Date (mm/dd/yy) Amount Account Paid from Check No.

3. You must include with this form a copy of the following: All cancelled checks, cashier’s
checks, wire transfers advices, checks received, or other reliable documentation evidencing
a cash transfer for each of the investments made in items 1 and the payments made in item
2 above.

4. If the investor is an entity, list all persons, or attach a list of persons who directly or
indirectly hold beneficial interest in the investor.
______________________________________________________________________________
_______________________________________________________________________________

You must com plete and return this Proof of Investment Form and the
Certification attached hereto as Exhibit “A”

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 EXHIBIT “A”

CERTIFICATION

IT IS A VIOLATION OF UNITED STATES FEDERAL LAW TO FILE A FRAUDULENT

CLAIM. CONVICTION CAN RESULT IN A FINE OR IMPRISONMENT OR BOTH.

IT MAY ALSO BE A CONTEMPT OF COURT IN THE ACTION STYLED SECURITIES

AND EXCHANGE COMMISSION V. BRYCAR FINANCIAL CORPORATION AND BRYAN
J. EGAN; NO. CV-S-00-1125-LDG-LRL FOR ANY FALSE OR FRAUDULENT
INFORMATION SUBMITTED ON THIS PROOF OF INVESTMENT FORM.

The undersigned certifies under penalty of perjury that the information contained in this
Certified Proof of Investment Form is true and accurate to the best of the undersigned’s
knowledge, information and belief.

Date: Signature:

Date: Signature:

(If ownership of the account is shared, all must sign above. Give each owner’s name, address,
phone number, and extent of ownership on a signed separate sheet. If other than a personal account,
e.g., corporate, trustee, custodian, etc., also state your capacity and authority. Please supply the trust
agreement or other proof of authority.)

This Proof of Investment Form must be completed, signed, and returned promptly,
together with supporting documentation, etc. to:

JOHN E. HAM, ESQ., RECEIVER

BRYCAR FINANCIAL CORPORATION
c/o Santoro, Driggs, Walch, Kearney, Johnson & Thompson
3773 Howard Hughes Parkway, Suite 290N
Las Vegas, Nevada 89109
1-702-791-0308 - telephone
1-702-791-0289 - facsimile

(If you would like to telecopy the completed form to the Receiver, please use the enclosed fax cover
sheet. Please also send the originals by certified mail return receipt requested or by courier to the
above address.)

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 FAX COVER SHEET

TO: John E. Ham, Esq. FAX NO.: (702) 791-0289

FROM:

TELEPHONE NO. FAX NO.:

RE: Investor Questionnaire

DATE: NUMBER OF PAGES

(Including cover sheet)

CONFIDENTIAL INFORMATION

The information contained in this facsimile message is attorney privileged and confidential
information intended only for the use of the individual or entity named above. If the
reader of this message is not the intended recipient, you are hereby notified that any
dissemination, distribution, or copying of this communication is strictly prohibited. If you
have received this communication in error, please immediately notify us by telephone at
1-702-791-0308 and return the original message to John E. Ham, Receiver, 3773
Howard Hughes Parkway, Suite 290N, Las Vegas, Nevada 89109 at the above address
via U.S. Postal Service. We will remit any reasonable postage charges incurred by you.
Thank You.

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