State of California Secretary of State PROOF OF ESCROW ACCOUNT DISCOUNT BUYING ORGANIZATION (Civil Code Section 1812.101 et seq.) Instructions: 1. Form is to be executed by a bank officer. 2. Complete and mail to: Secretary of State, Special Filings Unit P.O. Box 942877, Sacramento, CA 94277-0001, (916) 653-3984 (Office Use Only) For the purpose of complying with Civil Code Section 1812.101, it is hereby stated that the below named discount buying organization has established an escrow account in the amount of fifty thousand dollars ($50,000) for the purpose of providing refunds to members. ______________________________________________________________________________________________ (Name of Organization) _____________________________________________________________________________________________________________________ (Street Address of Organization) _______________________________________________________ (Name of Principal Officer of Organization) ______________________________________ (Title) This form serves as written notice to the Secretary of State of the State of California of the establishment of an escrow account for the above named organization, pursuant to Civil Code Section 1812.101. It is further acknowledged that we are a federally insured bank or federally insured financial institution independent of the above named organization, authorized to transact business in California. Executed in _________________________________________________ on _______________________________ (City, State) (Date) ___________________________________________________________ (Name of FDIC Bank or Financial Institution) _________________________________________________ (Street Address of FDIC Bank or Financial Institution) _________________________________________________ (City, State, Zip) _________________________________________________ (Typed or Printed Name of Authorized Officer of Financial Institution) _________________________________________________ (Signature of Authorized Officer of Financial Institution) SF SB-916 (Rev 03/2005) American LegalNet, Inc. www.USCourtForms.com