IDAHO DEPARTMENT OF FINANCE Securities Bureau PO Box 83720 Boise, ID 83720-0031 QUARTERLY REPORT FORM FOR SMALL MINING ISSUES 1. Name of Issuer: _______________________________________ Qtr.Ending: ______________________ Address: _____________________________________________ Permit No.: ______________________ 2. Number of shares sold this report: _______________ To date under Permit: _____________________ 3. Number of purchasers this report: _______________ To date under Permit: _____________________ 4. Amount of money obtained from sales this report: ______________________ To date:_________________ 5. Purpose for which monies were used including: This Report Year to Date a. Salaries & Wages $ __________ $ ______________ b. Repairs $ __________ $ ______________ c. Rent $ __________ $ ______________ d. Taxes $ __________ $ ______________ e. Interest $ __________ $ ______________ f. Advertising $ __________ $ ______________ g. Promotional Expense $ __________ $ ______________ h. Commissions to selling persons $ __________ $ ______________ Exploration, Development and Mining i. Operation: 1. Payroll $ ______________ 2. Supplies $ ______________ 3. Equipment $ ______________ 4. Legal fees $ ______________ 5. Accounting $ ______________ 6. Engineering $ ______________ 7. Geological $ ______________ 8. Royalties $ ______________ 9. Lease Expense $ ______________ TOTAL: $ ___________ $ _____________ ============ ============= Total monies used $ ___________ $ _____________ (Issuer) ____________________________ (Title) ____________________________ >>>> 2 STATE OF _______________) ) ss:COUNTY OF ) On this _________ day of _________________, 20___, personally appeared before me, notary public in and for said county and state, __________________________________________ who being first duly sworn, deposes and says that he is ______________________________ of _________________________________________ described in the foregoing report; that he has read said report and all exhibits and statements filed therewith and made a part thereof and knows the contents thereof and that the facts therein stated are true; that he has full authority to execute said report; and that saidth repe free ort is act and deed of said registrant. SUBSCRIBED AND SWORN to before me this ________ day of ______________________, 20____. ________________________________________________ NOTARY PUBLIC FOR STATE OF _________________________ Residing at:______________________________ My commission expires:___________________________ C:\)-40.7(MyFiles\)-40.7(Qtlyr ptmine.wpd