STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT REQUEST FOR DESIGNATION AS AN EXEMPT ORGANIZATION PURSUANT TO SUBDIVISION (k) OF SECTION 25100 OF THE CORPORATE SECURITIES LAW OF 1968 DBO260.100.1 (Register 2002, No. 39) (Rev. 10-17) File No.002 (Insert file number of previous filings002 before the Department, if any.)002 Fee: $50002 Date of Request002 1.003 (Name of Applicant) 2.003 (Principal business address of applicant) 3.003 (State whether applicant is a corporation, trust or other entity) 4.003 Is applicant organized exclusively for educational, benevolent, fraternal, religious, charitable, social, or reformatory purposes and not for pecuniary profit? 5.003 (Name and address of person to whom correspondence regarding this request should be002 addressed)002 6.003 Describe briefly the type of activities engaged in by applicant. 7.003 There are attached hereto as exhibits, if applicable, the following which are hereby incorporated by reference: A. Financial statements, including a balance sheet of recent date and a profit and loss statement for each of the three fiscal years preceding the date of the balance sheet. The balance sheet and profit and loss statements should reflect all assets acquired from donors of property in consideration of the payment to the donor or other persons of income or specified periodic payments. B. A list containing the complete names and other business affiliations of the directors, officers, trustees and/or other persons who will be charged with the activities and operation of the applicant. C. A statement setting forth the scope and nature of any investment advisory services that the applicant has utilized or proposes to utilize, or (if no such services are utilized) the investment experience of the persons to manage the investment portfolio. D. An opinion of counsel with respect to the tax consequences to the prospective donors of002 property.002 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT REQUEST FOR DESIGNATION AS AN EXEMPT ORGANIZATION PURSUANT TO SUBDIVISION (k) OF SECTION 25100 OF THE CORPORATE SECURTIES LAW OF 1968 DBO260.100.1 (Register 2002, No. 39) (Rev. 10-17) Page 2 of 2 The applicant has duly caused this application to be signed on its behalf by the undersigned, thereunto duly authorized. (Applicant) By (Title) I certify (or declare) under penalty of perjury under the laws of the State of California that I have read this application and the exhibits thereto and know the contents thereof, and that the statements therein are true and correct. Executed at , on , 20 . (Place) (Date) (Signature) American LegalNet, Inc. www.FormsWorkFlow.com