Form 1 Registration Statement Permit No. Securities Sales Report To The Commissioner of Insurance of The State of Iowa Securities Bureau If a registration statement is effective in Iowa, this securities sales report form or a similar form must be filed on a timely basis with the Administrator. Management Investment Companies, Unit Investment Trusts, Face Certificate Companies and Uniform Investment Companies may file Form USR-1 or the Uniform Notice Filing (Form NF). Annual securities sales reports must be filed with the administrator within ninety (90) days after the annual anniversary date of the registration statement's effective date in Iowa. Final securities sales reports must be filed with the administrator within (90) days after the offer and sale of securities pursuant to this registration statement ceases in Iowa. This is (an annual sales report) (a final sales report) beginning on 200 , and ending on , 200 . , Issuer' s name: Address: Correspondent's Name: Correspondent's Address: Correspondent's Telephone: Correspondent's Fax Number: Securities Registered During this Period: $ Securities Sold During this Period: $ I certify that the aforesaid information is complete and accurate. Date: , 200 (Issuer, Correspondent, or Applicant) By: (Authorized Signature) American LegalNet, Inc. www.USCourtForms.com