AFFIDAVIT OF ISSUER/DEALER ACTIVITY NORTH DAKOTA SECURITIES DEPARTMENT SFN 53493 (10-2013) Securities Department 600 E Boulevard Ave Dept 414 Bismarck ND 58505 (701) 328-2910 www.nd.gov/securities Name of Applicant: Applicant does hereby certify: 1. That the above-named Applicant has offered for sale or sold securities, and/or solicited investors in this state. (Attach a list of names and addresses of North Dakota residents solicited in our state.) 2. That the above-named Applicant has not offered for sale or sold any securities, and/or solicited investors in this state. 3. That the above-named Applicant has offered for sale and sold securities, and/or solicited investors in this state pursuant to an exempt transaction. (Please specify which exemption was relied upon): I, on behalf of (Name of Applicant), acknowledge the foregoing to be truthful with full knowledge that misrepresentation of such facts to the Securities Department of the State of North Dakota may result in administrative action by the Department. Signature of Officer, Partner or Sole Proprietor: Subscribed and sworn to before me this day of , 20 . Notary Public County of (NOTARIAL SEAL) State of My commission expires on American LegalNet, Inc. www.FormsWorkFlow.com