SECURITIES AND BUSINESS REGULATION 2 Martin Luther King, Jr. Drive, S.E. Ste 802, West Tower Atlanta, Georgia 30334 (404) 656-3920 http://www.sos.state.ga.us/securities/ ROBERT D. TERRY Assistant Commissioner of Securities KAREN HANDEL Commissioner of Securities STATEMENT DEMONSTRATING ELIGIBILITY FOR REGISTRATION BY NOTIFICATION Georgia Securities Act of 1973, as amended O.C.G.A. §10-5-5(d) 1. Name of issuer: 2. How long has the issuer been in continuous operation? If less than 5 years, give name of predecessors and state length of time each has been in continuous operation: 3. Has there been any default during the current fiscal year, or within the 3 preceding fiscal years, in the payment of principal, interest or dividends on any security, of the issuer or any predecessor, with a fixed maturity or a fixed interest or dividend provision? 4. Give the following information as to all securities without a fixed maturity or a fixed interest or dividend provision: Class of Securities Now Outstanding No. of Units Maximum Offering Price Per Unit* 1 $ Market Price Per Unit* Book Value Per Unit**2 $ $ Amount***3 $ $ TOTAL $ 1 *The maximum offering price or the market price may be on a day selected by the applicant but must be within 30 days before the date of filing this registration statement. 2 **Book value may be on a day selected by the applicant but must be within 90 days before the date of filing this registration statement. Book value may be used only if there is neither a readily determinable market price nor a cash offering price. (If book value is used, attach balance sheet from which the same is determined.) 3 ***The amount extended is the product of either (1) the number of units times the higher of the maximum offering price or the market price, or (2) the number of units times the book value. Form 8-NE Rev. 1/2007 American LegalNet, Inc. www.FormsWorkflow.com 5. If none of the classes of securities now outstanding, listed in answer to Question 4 above, was an outstanding class of securities of the issuer, or any of its predecessors for 3 full years, then complete the schedule below using the footnoted instructions in Question 4. Class of Securities Now Outstanding****4 No. of Units Maximum Offering Price Per Unit* $ Market Price Per Unit* $ Book Value Per Unit** $ Amount*** $ $ 6. TOTAL $ State net earnings of the issuer and any predecessors during the past 3 fiscal years, determined in accordance with generally accepted accounting practices which are applicable to all securities without a fixed interest or dividend provision. (These must be figures pursuant to certified audit with evidence thereof attached.) Net Earnings Fiscal Year ended " " " " " $ " TOTAL $ Average (1/3) $ 5% of the total in Question 4 is: $ 5% of the total in Question 5 is: $ Date of Signing: By: Name of Applicant: (Officer, Partner or Proprietor) (Title) 4 ****Include all securities which will be outstanding if all the securities being offered or proposed to be offered are issued, whether or not they are proposed to be registered or offered in this state. Form 8-NE Rev. 1/2007 American LegalNet, Inc. www.FormsWorkflow.com