TO THE COMMISSIONER OF CORPORTIONS OF THE STATE OF CALIFORNIA: STATEMENT OF TRANSFEREE TO ACCOMPANY APPLICATION FOR CONSENT TO TRANSFER SECURITIES SUBJECT TO LEGEND OR ESCROW CONDITION (If securities are to be received in pledge, so state.) The undersigned intends to purchase* _________________________ shares or units (number) of ________________________________________________________________________ (Description of security, e.g., $10 common, Class A common) issued by __________________________________________________________________ (Name of Issuer) from ________________________________________ and makes the following statements: 1. I have received from the issuer and/or the transferor a recent financial statement of the issuer and such additional information with respect to the issuer as I have deemed necessary to make an independent evaluation of the business prospects of the issuer and the fairness of the investment: (If answered in the negative, explain fully.) Yes No 2. I am a director and/or an office of issuer ……………………………… 3. (a) I will actively participate in the operation of issuer’s business and devote my full time or a substantial portion of my time thereto, with an opportunity to be fully aware of all of issuer’s affairs…………………………………………………………….. Yes No (b) I will be compensated for such services…………………………… Yes No 4. Are the securities being purchased promotional shares subject to waivers of assets and Yes No dividend? (See Sections 260.141 and 260.141.1 of the rules.)……. 5. If the issuer is not a partnership and all parts of questions 2 and 3 above are answered in the negative, attach a separate signed statement elaborating on the items shown below: (a) The length of time officers and directors of issuer have been known, and the nature of prior business dealings with any officer or director of issuer or with the issuer. (b) Any prior investment experience in a business of similar size and nature. (c) Whether the amount of the proposed investment in issuer is in excess of 10% of either the net worth or the annual income of the transferee. (d) Whether the transferee has received advice from any attorney, accountant or other professional adviser independent of the issuer. (e) How transferee became aware of proposed investment. 6. If the issuer is a partnership, complete the following: (a) My annual income is in excess of $____________________________. (b) My net worth (exclusive of my home, its furnishings and my automobiles) is in excess of $________________________. 260.151(b) (Register 2002, No. 39) 1 Yes American LegalNet, Inc. www.FormsWorkFlow.com No 7. (a) I am acquiring the securities as record and beneficial owner. … Yes No (b) I am acquiring the securities as beneficial owner and not as record owner. ………... Yes No The record owner is _____________________________________ (c) I am acquiring the securities as record owner and have no beneficial interest therein. …………………………………………………………………… Yes No The beneficial owner is _________________________________________. *Include rights, warrants, and options and the securities to be transferred upon exercise thereof. If the transferee is other than an individual, the name of the entity should be typed or printed beside the signature line exactly as shown in Item 4 of the Transferor’s Application (Form 260.151). The signature should show the name and title of the person authorized to sign for the transferee. I certify (or declare) under penalty of perjury under the laws of the State of California that I have read this Statement of Transferee and know the contents thereof, and that the statements therein are true and correct. Executed at __________________________________________, ________________, 20 __. (Place) (Date) _________________________________________ (Name of Entity) ________________________________ (Signature of Transferee) ________________________________ (Title) 2 American LegalNet, Inc. www.FormsWorkFlow.com