Document processing fee If document is filed on paper $150.00 If document is filed electronically Currently Not Available Fees & forms/cover sheets are subject to change. To file electronically, access instructions for this form/cover sheet and other information or print copies of filed documents, visit www.sos.state.co.us and select Business. Paper documents must be typewritten or machine printed. ABOVE SPACE FOR OFFICE USE ONLY Statement of Share and Equity Capital Exchange filed pursuant to §7-90-301, et seq. and §7-56-605 or §7-111-105 Colorado Revised Statutes (C.R.S.) 1. Entity name or true name of each entity the shares of which will be acquired: ______________________________________________________ (Enter name exactly as it appears in the records of the secretary of state if applicable) ID number: Principal office street address: _____________________ ______________________________________________________ (Street name and number) ______________________________________________________ __________________________ ____ (City) (Province ­ if applicable) (State) (Country ­ if not US) ____________________ (Postal/Zip Code) _______________________ ______________ Principal office mailing address: ______________________________________________________ (if different from above) (Street name and number or Post Office Box information) ______________________________________________________ __________________________ ____ (City) (Province ­ if applicable) (State) (Country ­ if not US) ____________________ (Postal/Zip Code) _______________________ ______________ Entity name or true name: ID number: Principal office street address: ______________________________________________________ (Enter name exactly as it appears in the records of the secretary of state if applicable) _____________________ ______________________________________________________ (Street name and number) ______________________________________________________ __________________________ ____ (City) (Province ­ if applicable) (State) (Country ­ if not US) ____________________ (Postal/Zip Code) _______________________ ______________ Principal office mailing address: ______________________________________________________ (if different from above) (Street name and number or Post Office Box information) ______________________________________________________ __________________________ ____ (City) (Province ­ if applicable) (State) (Country ­ if not US) ____________________ (Postal/Zip Code) _______________________ ______________ SHARE Page 1 of 3 Rev. 6/16/2005 American LegalNet, Inc. www.FormsWorkFlow.com Entity name or true name: ______________________________________________________ (Enter name exactly as it appears in the records of the secretary of state if applicable) ID number: Principal office street address: _____________________ ______________________________________________________ (Street name and number) ______________________________________________________ __________________________ ____ (City) (Province ­ if applicable) (State) (Country ­ if not US) ____________________ (Postal/Zip Code) _______________________ ______________ Principal office mailing address: ______________________________________________________ (if different from above) (Street name and number or Post Office Box information) ______________________________________________________ __________________________ ____ (City) (Province ­ if applicable) (State) (Country ­ if not US) ____________________ (Postal/Zip Code) _______________________ ______________ (If there are more than three such entities, mark this box and include an attachment stating the entity name, ID number, and the principal office address of each additional entity.) 2. Entity name of acquiring entity: ______________________________________________________ ID number: Principal office street address: _____________________ ______________________________________________________ (Street name and number) ______________________________________________________ __________________________ ____ (City) (Province ­ if applicable) (State) (Country ­ if not US) ____________________ (Postal/Zip Code) _______________________ ______________ Principal office mailing address: ______________________________________________________ (if different from above) (Street name and number or Post Office Box information) ______________________________________________________ __________________________ ____ (City) (Province ­ if applicable) (State) (Country ­ if not US) ____________________ (Postal/Zip Code) _______________________ ______________ 3. If this share exchange is pursuant to §7-111-105, C.R.S., the following statement applies: The acquiring corporation acquires shares of the other corporations. 4. Additional information may be included. If applicable, mark this box stating the additional information. 5. (Optional) Delayed effective date: Notice: Causing this document to be delivered to the secretary of state for filing shall constitute the affirmation or acknowledgment of each individual causing such delivery, under penalties of perjury, that the document is the individual's act and deed, or that the individual in good faith believes the document is the act and deed of the person on whose behalf the individual is causing the document to be delivered for filing, taken in conformity with the requirements of part 3 of article 90 of title 7, C.R.S., the constituent documents, and the organic SHARE Page 2 of 3 Rev. 6/16/2005 American LegalNet, Inc. www.FormsWorkFlow.com and include an attachment ______________________ (mm/dd/yyyy) statutes, and that the individual in good faith believes the facts stated in the document are true and the document complies with the requirements of that Part, the constituent documents, and the organic statutes. This perjury notice applies to each individual who causes this document to be delivered to the secretary of state, whether or not such individual is named in the document as one who has caused it to be delivered. 6. Name(s) and address(es) of the individual(s) causing the document to be delivered for filing: ____________________ ______________ ______________ _____ (Last) (First) (Middle) (Suffix) ______________________________________________________ (Street name and number or Post Office Box information) ______________________________________________________ __________________________ ____ ____________________ (City) (Province ­ if applicable) (State) (Country ­