*DSMITHFIRST* DSMITH - Gilardi & Co, LLC
*DSMITHFIRST* DSMITH - Gilardi & Co, LLC
*DSMITHFIRST* DSMITH - Gilardi & Co, LLC
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Official<br />
Office<br />
Use<br />
Only<br />
UNITED STATES DISTRICT COURT<br />
MIDDLE DISTRICT OF FLORIDA (ORLANDO)<br />
USA v. David A. Smith<br />
PETITION FOR REMISSION FORM<br />
Please Type or Print in the Boxes Below<br />
Do NOT use Red Ink, Pencil, or Staples<br />
Must Be Postmarked<br />
No Later Than<br />
May 15, 2013<br />
<strong>DSMITH</strong><br />
PART I: INVESTOR IDENTIFICATION<br />
Last Name M.I. First Name<br />
Last Name (<strong>Co</strong>-Investor)<br />
First Name (<strong>Co</strong>-Investor)<br />
<strong>Co</strong>mpany Name (Investor - If Investor is not an Individual) or Custodian Name if an IRA<br />
Trustee/Asset Manager/Investor of Record’s Name (If Different from Investor Listed Above)<br />
Account#<br />
Please indicate here and specify below if your investment was made through a third party, such as another investment club.<br />
Social Security Number<br />
Taxpayer Identification Number<br />
— — or —<br />
Telephone Number (Work)<br />
Telephone Number (Home)<br />
— — — —<br />
Email Address<br />
MAILING INFORMATION<br />
Address<br />
Address<br />
City State Zip <strong>Co</strong>de<br />
Foreign Province Foreign Postal <strong>Co</strong>de Foreign <strong>Co</strong>untry Name/Abbreviation<br />
FOR CLAIMS<br />
PROCESSING<br />
ONLY<br />
OB<br />
CB<br />
ATP<br />
KE<br />
ICI<br />
BE<br />
DR<br />
EM<br />
FL<br />
ME<br />
ND<br />
OP<br />
RE<br />
/ /<br />
SH<br />
FOR CLAIMS<br />
PROCESSING<br />
ONLY<br />
<strong>*<strong>DSMITH</strong>FIRST*</strong><br />
1
PART II. SCHEDULE OF INVESTMENTS AND RETURNS IN THE<br />
ELIGIBLE INVESTMENT CLUBS<br />
ELIGIBLE INVESTMENT CLUBS:<br />
A: OLINT C: OLINT TCI CORP<br />
B: OLINT CORP D: TCI FX TRADERS CORP<br />
A. Investments in the Eligible Investment Club(s) between February 3, 2005 through July 15, 2008, inclusive:<br />
INVESTMENTS<br />
Eligible<br />
Investment<br />
Club<br />
Select A-D<br />
from above<br />
Investment Date(s)<br />
(List Chronologically)<br />
M M / D D / Y Y<br />
Total Investment Amount<br />
(Excluding <strong>Co</strong>mmissions,<br />
Taxes and Fees)<br />
Please round off to<br />
the nearest whole dollar<br />
Proof of<br />
Investment<br />
Enclosed?<br />
1. / / $ . 0 0<br />
2. / / $ . 0 0<br />
3. / / $ . 0 0<br />
4. / / $ . 0 0<br />
5. / / $ . 0 0<br />
Y<br />
N<br />
Y<br />
N<br />
Y<br />
N<br />
Y<br />
N<br />
Y<br />
N<br />
B. Returns of Investments from the Eligible Investment Club(s) between February 3, 2005 through July 15, 2008, inclusive:<br />
RETURNS<br />
Eligible<br />
Investment<br />
Club<br />
Select A-D<br />
from above<br />
Return Date(s)<br />
(List Chronologically)<br />
M M / D D / Y Y<br />
Total Return of Invesment<br />
(Excluding <strong>Co</strong>mmissions,<br />
Taxes and Fees)<br />
Please round off to<br />
the nearest whole dollar<br />
Proof of<br />
Return<br />
Enclosed?<br />
1. / / $ . 0 0<br />
2. / / $ . 0 0<br />
3. / / $ . 0 0<br />
4. / / $ . 0 0<br />
5. / / $ . 0 0<br />
Y<br />
N<br />
Y<br />
N<br />
Y<br />
N<br />
Y<br />
N<br />
Y<br />
N<br />
If you require additional space, attach extra schedules in the same format as above. Sign and print your name on each additional page.<br />
FAILURE TO SIGN THIS PETITION MAY RESULT IN A DELAY IN PROCESSING OR THE REJECTION OF YOUR PETITION.<br />
*<strong>DSMITH</strong>SECOND*<br />
2
I (WE) DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES OF AMERICA THAT<br />
ALL OF THE FOREGOING INFORMATION SUPPLIED ON THIS PETITION FORM BY THE UNDERSIGNED IS TRUE AND<br />
CORRECT.<br />
Executed this________________ day of __________________________ in ___________________________________________<br />
(Month/Year)<br />
(City/State/<strong>Co</strong>untry)<br />
_____________________________________________<br />
(Sign your name here)<br />
_____________________________________________<br />
(Sign your name here)<br />
_____________________________________________<br />
(Type or print your name here)<br />
_____________________________________________<br />
(Capacity of person(s) signing, e.g.,<br />
Investor, Trustee, etc.)<br />
_____________________________________________<br />
(Type or print your name here)<br />
_____________________________________________<br />
(Capacity of person(s) signing, e.g.,<br />
Investor, Trustee, etc.)<br />
ACCURATE CLAIMS PROCESSING TAKES A SIGNIFICANT AMOUNT OF TIME.<br />
THANK YOU FOR YOUR PATIENCE.<br />
Reminder Checklist:<br />
1. Please sign the above declaration.<br />
2. If this Petition Form is being made on behalf of Joint<br />
Victims, then both must sign.<br />
3. Remember to attach copies of supporting documentation.<br />
4. Do not send original supporting documents. Send copies.<br />
5. Keep a copy of your Petition Form and all supporting<br />
documentation for your records.<br />
6. If you desire an acknowledgment of receipt of your<br />
Petition Form please send it Certified Mail, Return<br />
Receipt Requested.<br />
7. If you move, please send your new address to:<br />
USA v. David A. Smith<br />
Remission Administrator<br />
c/o <strong>Gilardi</strong> & <strong>Co</strong>. <strong>LLC</strong><br />
P.O. Box 990<br />
<strong>Co</strong>rte Madera, CA 94976-0990<br />
classact@gilardi.com<br />
8. Do not use red pen or highlighter on the Petition Form<br />
or supporting documentation.<br />
THIS PETITION FORM MUST BE POSTMARKED NO LATER THAN MAY 15, 2013<br />
AND MUST BE MAILED TO:<br />
USA v. David A. Smith<br />
Remission Administrator<br />
c/o <strong>Gilardi</strong> & <strong>Co</strong>. <strong>LLC</strong><br />
P.O. Box 990<br />
<strong>Co</strong>rte Madera, CA 94976-0990<br />
*<strong>DSMITH</strong>THIRD*<br />
3
THIS PAGE INTENTIONALLY LEFT BLANK<br />
*<strong>DSMITH</strong>FOURTH* 4
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