FIS 0568 (6/04) Office of Financial and Insurance Services Confidential Report Form INSTRUCTIONS: File this form to claim exemption from registration pursuant to Section 402(b)(9) of the Michigan Uniform Securities Act if a commission is paid or given for soliciting any purchaser in Michigan. All commissions that are paid shall be reflected on the books and records of the BrokerDealer, and shall be fully disclosed in writing to each prospective purchaser. The Report may be filed by the Issuer or Broker-Dealer and must be signed by an authorized agent or representative. Attach a list of the names and addresses of all Michigan purchasers. RETURN TO: Office of Financial and Insurance Services P.O. Box 30701 Lansing, MI 48909-8201 This form is issued under Act 265, PA 1964, as amended. This form must be completed for exemption from registration under Section 402(b)(9) of the Act if commissions are paid. Failure to file will disqualify the issuer from utilizing this exemption. American LegalNet, Inc. www.FormsWorkflow.com