— LeFever Mattson/Kenneth W. Mattson Investigation Questionnaire

Contact Information

First Name

Middle Name

Last Name

Date of Birth

Phone Number (no dashes, spaces, or parentheses)

Email Address

Address Line 1

Address Line 2

City

State

Country

ZIP/Postal Code

Questionnaire
For the below questionnaire, please only fill this form out on behalf of yourself or if you are the guardian or next of kin of a potential investor. If you know someone else that may be a potential investor and they are neither a minor nor deceased, please encourage them to fill out this form on their own behalf.

1. Have you invested with Kenneth W. (“Ken”) Mattson or in LeFever Mattson Inc., KS Mattson Partners LP, Divi Divi Tree, LP, or any other companies or real estate affiliated with Ken Mattson?

Yes
No

2. What is the total number of separate investments you have made with Ken Mattson, LeFever Mattson Inc., KS Mattson Partners LP, Divi Divi Tree, LP, or any other companies or real estate affiliated with Ken Mattson?

3. For each investment, please provide the date of your initial investment in MM/DD/YYYY format:

Date of Initial Investment #1

Date of Initial Investment #2

Date of Initial Investment #3

Date of Initial Investment #4

If more than 4 separate investments, please indicate additional investments in the text box below:

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4. For each investment, please provide the total dollar amount invested. Please enter according to the following format for each investment: (mm/dd/yyyy, dollar amount)

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5. For each investment, please indicate your method of payment: Check all that apply

Wire

Check

Custodian and/or Trust Company

Other

If other, please elaborate

6. For each investment, please provide your best estimate of the total amount you have received in returns on your investment since you initially invested:

7. Does LeFever Mattson or any of the Mattson-affiliated entities owe you any money on your investments?

Yes
No

If yes, how much?

8. For each investment for which you believe LeFever Mattson or any of the Mattson-affiliated entities owe you money, have you requested that your investment be returned to you?

Yes
No

9. With respect to each of your investments, what claims, if any, did Ken Mattson or others make about the nature of your investment, the amount of returns on your investment, source of returns, or safety of the investment?

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10. What were your primary modes of communication with Ken Mattson and others with respect to your investments? Check all that apply

In-Person

Text Message

Telephone

Other

If other, please elaborate:

11. Do you have copies of any communications with Ken Mattson, LeFever Mattson, KS Mattson Partners, or affiliated entities?

Yes
No

If yes, please send those documents to LFMInvestors@fbi.gov. Please include your first and last name in the subject line.

12. Do you have copies of any purchase agreements, partnership agreements, and tax documentation provided by those individuals or entities, or copies of financial transactions made as part of your investments?

Yes
No

If yes, please send those documents to LFMInvestors@fbi.gov. Please include your first and last name in the subject line.

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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LeFever Mattson/Kenneth W. Mattson Investigation Questionnaire

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