STATE OF CALIFORNIA 226DEPARTMENT OF BUSINESS OVERISGHT NOTICE OF ISSUANCE OF SHARES PURSUANT TO SUBDIVISION (h) OF SECTION 25102 OF THE CORPORATIONS CODE OR RULE 260.103, Title 10, CALIFORNIA CODE OF REGULATIONS DBO-260.102.8(a) (Rev. 10-17) (Department of Business Oversight Use Only) DEPARTMENT OF BUSINESS OVERSIGHT Fee Paid $ FILE No., if any: Receipt No. (Insert File Number(s) of Previous Filings Before the Department, If Any) FEE: $25.00 $35.00 $50.00 $150.00 $300.00(Check the appropriate amount of fee. See Corporations Code Section 25608(c)) Check one of the following: Notice pursuant to Section 25102(h) as to an issuance subject to qualification under Corporations Code Section 25110, unless exempted. Notice pursuant to Rule 260.103 as to an issuance subject to qualification under Corporations Code Section 25120, unless exempted. Name of Issuer State of Incorporation Address of Principal Place of Business Number and Street City State Zip Code 1.Is the issuer a "close corporation" as defined in Section 260.001, Title 10, California Code ofRegulations? Yes NoInstruction: Review Corporations Code Section 158 and Rule 260.001, Title 10, California Code ofRegulations.2.Under the exemption provided by Section 25102(h), shares of voting common stock have been or areproposed to be issued pursuant to this Notice beneficially to not more than 35 persons, whose namesare set forth below; together with the names of the corresponding record shareholders if other than thebeneficial shareholders: If additional space is needed for the names of shareholders, check this box and attach a separatesheet of paper to the Notice. American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA 226DEPARTMENT OF BUSINESS OVERSIGHT NOTICE OF ISSUANCE OF SHARES PURSUANT TO SUBDIVISION (h) OF SECTION 25102 OF THE CORPORATIONS CODE OR RULE 260.103, TITLE 10, CALIFORNIA CODE OF REGULATIONS DBO-260.102.8(a) (Rev. 10-17) Page 2 of 3 3. The value of the securities sold or proposed to be sold in the transaction, determined in accordance with the provisions of Section 25608(g) of the Corporations Code in connection with the fee required upon filing this notice, is: (a) $ in money $ in consideration other than money. (b) Change in rights, preferences, privileges or restrictions of or on outstanding securities under Rule 260.103. ($25 fee). 4. Immediately after the issuance and sale of such shares, the above-named issuer had or will have only one class of stock outstanding which was or will be owned beneficially by no more than 35 persons. Instruction: Review Sections 260.102.4 and 260.102.5, Title 10, California Code of Regulations. 5. The offer and sale of such shares was not nor will be accompanied by the publication of any advertisement and neither selling expenses nor promotional considerations were or will be given, paid or incurred in connection therewith. 6. To the best knowledge of the issuer, its shareholders (or proposed shareholders) have not entered into or granted, and presently do not intend entering into or granted, and presently do not intend entering into or granting a shareholders' agreement, voting agreement, irrevocable proxy or other arrangement the effect of which would cause the statements contained herein to be incorrect. Instruction: Review Sections 260.001 and 260.102.4, Title 10, California Code of Regulations. The undersigned officer of the issuer hereby declares that the foregoing is true under penalty of perjury. Executed at , this day of ,20. Name Title NOTE: If the officer signs this form in a jurisdiction which does not permit verifications under penalty of perjury, there must be attached a verification executed and sworn to before a notary public. American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA 226DEPARTMENT OF BUSINESS OVERSIGHT NOTICE OF ISSUANCE OF SHARES PURSUANT TO SUBDIVISION (h) OF SECTION 25102 OF THE CORPORATIONS CODE OR RULE 260.103, TITLE 10, CALIFORNIA CODE OF REGULATIONS DBO-260.102.8(a) (Rev. 10-17) Page 3 of 3 OPINION OF COUNSEL I certify that I am an active member of the State Bar of California. On the basis of the facts stated in the foregoing Notice and other information, including representations as to the type of consideration received or to be received, supplied to me by officials and shareholders of the issuer and by proposed issuees, it is my opinion that the exemption from qualification with the Commissioner of Business Oversight provided by Subdivision (h) of Section 25102 of the California Corporations Code is available for the offer and sale of the shares referred to in this Notice. Signature Firm Name Name of Member of the State Bar of California Address Tel. No. (This opinion of counsel must be signed by an active member of the State Bar for California. Type name of attorney, address, phone number and firm name, if any.) NOTE: If the issuer is a non-California corporation, a Consent to Service of Process as prescribed in the Commissioner's Rule 102.8(b) must be filed concurrently. American LegalNet, Inc. www.FormsWorkFlow.com