STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT STATEMENT OF TRANSFEREE TO ACCOMPANY APPLICATION FOR CONSENT TO TRANSFER SECURITIES SUBJECT TO LEGEND OR ESCROW CONDITION DBO260.151(b) (Register 2002, No. 39) (Rev. 10-17) TO THE COMMISSIONER OF BUSINESS OVERSIGHT OF THE STATE OF CALIFORNIA: (If securities are to be received in pledge, so state.) The undersigned intends to purchase* shares or units of (number) (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 issuerand such additional information with respect to the issuer as I have deemed necessary tomake an independent evaluation of the business prospects of the issuer and the fairness of theinvestment: (If answered in the negative, explain fully.) Yes No 2. Yes No 3. substan Yes No Yes No 4. Are the securities being purchased promotional shares subject to waivers of assets anddividend? (See Sections 260.141 and 260.141.1 of the rules) Yes No 5. If the issuer is not a partnership and all parts of questions 2 and 3 above are answered in thenegative, 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 priorbusiness 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 thenet worth or the annual income of the transferee. (d)Whether the transferee has received advice from any attorney, accountant or otherprofessional 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 $. (b)My net worth (exclusive of my home, its furnishings and my automobiles) is in excess of$. American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA DEPARTMENT OF BUSINESS OVERSIGHT STATEMENT OF TRANSFEREE TO ACCOMPANY APPLICATION FOR CONSENT TO TRANSFER SECURITIES SUBJECT TO LEGEND OR ESCROW CONDITION DBO260.151(b) (Register 2002, No. 39) (Rev. 10-17) Page 2 of 2 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 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) American LegalNet, Inc. www.FormsWorkFlow.com