Illinois Secretary of State Securities Department Investor Statement 421 E. Capitol Ave., 2nd Floor Springfield, IL 62701 · 217-782-2256 69 W. Washington St., Ste. 1220 Chicago, IL 60602 · 312-793-3384 800-628-7937 By completing this statement you will be assisting the Illinois Securities Department with the inquiry of a Company, Dealer, Investment Advisor, etc. The information received will enable the Securities Department to conduct a more accurate inquiry. INVESTOR INFORMATION: Name: Age: Address: City: Home Telephone Number: Please indicate the most convenient day to be contacted: Monday Tuesday Wednesday Thursday Friday Please indicate the most convenient time and place to be contacted: Work (indicate time): Home (indicate time): INQUIRY REFERENCE TO: Name (Company, Firm/Dealer, Investment Advisor, Operator, Driller or Individual): Address: City: County: State: ZIP: State: Work Telephone Number: ZIP: Name, Title/Position, Address and Telephone Number of first person you dealt with: CONTACT INFORMATION: Did you know the person who contacted you prior to the sale? Yes No Did the salesperson come to your home? Yes No Did to go to the firm's place of business? Yes No Did you meet the salesperson away from the firm's place of business (such as a convention, your business, restaurant or other location)? Yes (indicate other location): No Printed by authority of the State of Illinois. December 2015 -- 100 -- SEC 318.1 American LegalNet, Inc. www.FormsWorkFlow.com Did you receive a telephone call from the firm? Yes No Did you call the firm? Yes No Did you receive information in the mail? Yes No Did you respond to a radio, television or newspaper advertisement? Yes No DESCRIBE SECURITY PURCHASED OR OFFERED: Common Stock Name: Describe Promissory Notes or Investment Contract: Describe Bonds or Debentures: Limited Partnership Interests: Yes No Fractional undivided interest in oil, gas or other mineral leases: Yes No Describe other types of securities: Number of notes/shares purchased and amount paid: Date of transaction or date agreement was signed: To whom was payment given or sent: FORM OF PAYMENT: Cash Credit Card Loan Promissory Note Check (indicate date check was canceled and check number): Other form of payment (please specify): MISCELLANEOUS: Have you filed an inquiry or complaint with the company, firm, dealer or investment advisor? Yes No If yes, indicate Name, Address, and Telephone Number of Person or Agency, and Date: How was payment sent (mail, courier, UPS, etc.): American LegalNet, Inc. www.FormsWorkFlow.com What, if any, action has been taken? Have you obtained private legal counsel? Yes No If yes, indicate Name, Business Address and Telephone Number of Attorney: ATTACH COPIES OF ANY DOCUMENTS REGARDING THIS MATTER. (Include the front and back of all canceled checks, or other evidences of payment of the Business Broker's fee.) Are you willing to be interviewed by a Securities Department investigator? Yes No Are you willing to testify if formal proceedings are commenced? Yes No DESCRIBE IN DETAIL ANY OTHER INFORMATION THAT MAY HELP THE SECURITIES DEPARTMENT UNDERSTAND THE AGREEMENT AND ANY DISCUSSION BETWEEN YOU AND THE BUSINESS BROKER. IF MORE SPACE IS NEEDED, PLEASE ATTACH ADDITIONAL SHEETS: Signature of Borrower Date American LegalNet, Inc. www.FormsWorkFlow.com