Notice of Exempt Securities Transactions Under AS 45.55.900(b)(5)(A) (To be filed along with the fee required by 3 AAC 08.920(6)) Please fill out this form and submit to: Administrator of Securities Alaska Division of Banking, Securities, and Corporations P.O. Box 110807 Juneau, AK 99811-0807 (907) 465-2521 1. Name, Address and Telephone number of contact person filing this notice: Full Name Address Phone Fax The person signing this form must show name & address above. If different from the contact person, show information on signer as well. The E-mail address given must show the address to send the order of effectiveness. 2. Name, Address and Telephone number of Issuer Entity requesting exemption: Name of Entity Address Phone q No Formed, or to be formed, as an Alaska domestic (Corp., LP, LLP, or LLC) under Alaska Statutes Title 10 or 32. (This information is for statistical purposes only.) 4. Please provide a onoonlyonlyon;only. terms of the offering (including security and price). If more brief description of space is needed, use page two or include attachments. 3. q Yes 5. Date sales are to commence: (may not be sooner than 2 days after the filing date of the exemption notice or as determined by the administrator) 6. Describe any special circumstances you ask the administrator to consider. If more space is needed, use page two or include attachments. Waiver requests must include full disclosure to the administrator of the facts and relevant material factors relating to the request. 08-106 (rev. 8/01) American LegalNet, Inc. www.USCourtForms.com By filing this document, I affirm the following: • • • • • • • • Sales will be made to no more than 10 persons in this state, other than those designated at AS 45.55.900(b)(4), during the 12 consecutive-month-period-of-effectiveness regardless of whether the seller or any of the buyers is then present in this state. (See Attachment B below, do not return to agency). As a consequence of this sale the number of security holders will not exceed 20 in total. It is understood that “in this state” has the same meaning as that phrase is used at AS 45.55.980(c) (see Attachment A below, do not return to agency); A commission or other remuneration will not be paid or given directly or indirectly for soliciting a prospective buyer in this state; A legend will be placed on the certificate or other document evidencing ownership of the security, stating that the security is not registered under The Alaska Securities Act, AS 45.55, and cannot be resold without registration under AS 45.55 or exemption from such registration; Offers will be made without public solicitation or advertisement; This notice filing is the notice required under AS 45.55.900(b)(5)(A)(iv), and must be in the hands of the administrator, along with the fee described at 3 AAC 08.910(6), at least two days before any sales are made, unless the two-day waiting period is waived by the administrator in the order of effectiveness; and The offering will comply with the limitations of 3 AAC 08.910(3)(E). Under AS 45.55.160, it is UNLAWFUL to file with the Administrator of Securities any document that would make, or cause to be made, an untrue or misleading statement of material fact or omit to state a material fact necessary so as to make the statement made not misleading. Signature of attorney or principal (please describe which) Title Date E-mail address (to receive notice of effectiveness): Additional space (Please refer to ¶ number being amplified): 08-106 (rev. 8/01) For Office Use Only American LegalNet, Inc. www.USCourtForms.com