FIS 0559 (5/04) Office of Financial and Insurance Services This form is issued under Act 265, PA 1964, as amended. You must file this form as required by Order of the Administrator pursuant to Section 305(i) and Rule 705.4 SECURITIES REPORT Issuer File No. Description of Securities Report Date (Report date is the expiration of the Registration Order unless offering is terminated prior to the expiration of the Registration Order; in which case, the report date is the date of termination.) Report of Sales: Registered in Michigan $ This report is accompanied by a) $ Date offering terminated Any filing fee due: b) Total Sold in Michigan Any information required to be filed to comply with orders of, or commitments to, the Office I, (Name) (Organization) do solemnly swear that I have read the foregoing report and all exhibits in connection therewith, and, in the case where I am executing this report as a principal of the Issuer, that I have knowledge and that the facts and representations contained therein are true to the best of my knowledge and belief; and, in the case where I am executing this report for other than the Issuer, that I have fully set forth the sources of the information contained in the report and exhibits thereto, and that such sources are reliable to the best of my knowledge and belief. Signature Date signed RETURN TO: Office of Financial and Insurance Services Securities Section P.O. Box 30701 Lansing, MI 48909-8201 American LegalNet, Inc. www.USCourtForms.com