State of California Secretary of State DECLARATION OF INCOME INVENTION DEVELOPER (Business and Professions Code Section 22370 et seq.) Complete and mail to: Secretary of State, P.O. Box 942870, Sacramento, CA 94277-2870. (916) 653-3984 (Office Use Only) The undersigned does hereby state and declare: That I am the _______________________________________________________________________________________ Title of Officer of________________________________________________________________________________________________________ Name of Business developer located at _________________________________________________________________________________________ Street Address __________________________________________________________________________________________________ City State Zip Code That for the purpose of complying with California Law, I hereby state and declare that the total amount of fees charged buyers by said invention developer organization under contracts entered into between the invention developer organization and such buyers during the previous 12 months from ________________________________to________________________________ Date Date was in the sum of $___________________________. Amount I further declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct of my own knowledge. Executed on __________________________at______________________________________, ____________________ Date City State ________________________________________________ Signature of Declarant ________________________________________________ Typed or Printed Name of Declarant THIS DOCUMENT IS NOT SUBJECT TO PUBLIC INSPECTION SEC/STATE FORM NPSF 409D Rev 04/2015 American LegalNet, Inc. www.FormsWorkFlow.com