— Seeking Victim Information on CBA Pharma Inc

Contact Information

First Name

Middle Name

Last Name

Date of Birth

Year / Month / Day

Phone Number (no dashes, spaces, or parentheses)

Email Address

Address Line 1

Address Line 2

City

State

Country

ZIP/Postal Code

Questionaire

1. If filling out this form on behalf of a business or organization, please provide the name of the business or organization.

2. Did you, your business, or your organization ever invest money into CBA Pharma, Inc.?

a. Yes
b. No

3. If your answer to Question 2 was “Yes,” how much did you, your business, or your organization invest? On what date(s) did your investment(s) occur?

4. If your answer to Question 2 was “Yes,” how were funds provided to CBA Pharma? Mark all that apply:

a. Check

b. Wire Transfer

c. Other

5. How were you first introduced to CBA Pharma? Approximately what date did the introduction occur?

6. Who did you communicate with at CBA Pharma and when did those communications take place?

7. Did you receive information about CBA Pharma’s Royalty Offering?

a. Yes
b. No

8. Did you invest money into CBA Pharma’s Royalty Offering?

a. Yes
b. No

9. If your answer to Question 8 was “Yes,” how much did you invest? On what date(s) did the investments occur?

10. Have you ever requested any of your invested money back? If so, what response was provided? From whom?

11. Have you ever received a product called Brightstar from CBA Pharma?

a. Yes
b. No

12. If your answer to Question 11 was “Yes,” did you receive any direction on Brightstar’s use?

a. Yes
b. No

13. If your answer to Question 12 was “Yes,” from whom did you receive direction about Brightstar? What ailments does Brightstar cure?

14. What is your understanding of the estimated timeline for FDA approval of CBT-1? If you can recall, please provide the source of information that led to this understanding.

15. Is there any additional information you wish for the investigative team to know about CBA Pharma, CBT-1, Brightstar, and/or CBA Pharma’s Royalty Offering?

Privacy Act Statement

The FBI is authorized to collect the information on this form by one or more of the following provisions: Title 28, United States Code, sections 533 and 534; Title 28, Code of Federal Regulations, section 0.85; and the Attorney General Guidelines for Victim and Witness Assistance. The information requested will assist the FBI in providing you with assistance to which crime victims are entitled under federal law. You do not have to provide the requested information; however, failure to do so may hinder the FBI in providing you with crime victim assistance. The information collected on this form is protected by the Privacy Act of 1974, as amended, Title 5, United States Code section 552a, and is maintained in the FBI’s Central Records System, DOJ/FBI-002, a description of which was published in the Federal Register at 63 Fed. Reg. 8671 (Feb. 20, 1998) and which may be viewed at www.justice.gov/opcl/doj-systems-records#doj

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Seeking Victim Information on CBA Pharma Inc

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