BARBARA K. CEGAVSKE Secretary of State 202 North Carson Street Carson City, Nevada 89701-4201 (775) 684-5708 Website: www.nvsos.gov ATTACH FORM ONLY IF CLAIMING A STATE BUSINESS LICENSE EXEMPTION *270104* Declaration of Eligibility for State Business License Exemption (This form must be notarized) USE BLACK INK ONLY - DO NOT HIGHLIGHT ABOVE SPACE IS FOR OFFICE USE ONLY This form must accompany the List of Officers only if claiming exemption from the State Business License. Please provide the information requested only for the exemption for which you claim eligibility. Failure to provide the requested information or to notarize this document will result in a rejected filing, which could result in late fees. Entity Name: NV Business I.D. Number: 001 - Governmental Entity This entity is an incorporated or unincorporated agency or instrumentality of the United States government or any state government; a corporation wholly owned by the United States government; or county, city, district, or other political subdivision of a state. 002 - 501(c) Nonprofit Entity This entity is qualified as a 501(c) Nonprofit Entity pursuant to Title 26 U.S.C. Section 501(c). Please provide the Internal Revenue Service (IRS) issued Federal Employer Identification Number (FEIN) 005 - Motion Picture Company Is the primary purpose of this entity to create or produce motion pictures, as defined in NRS 231.020? If yes to above question, does the creation or production of motion pictures occur in Nevada? Yes If so, please provide Nevada Film Office registration number: 006 - NRS 680B.020 Insurance Company Are the activities of this entity regulated through a license or certificate of authority granted by the Division of Insurance pursuant to NRS Title 57? Yes No If yes, provide license or certificate of authority number I declare under penalty of perjury, as a representative authorized by statute to file on behalf of the above named entity, that the declarations indicated above are true and correct. Yes No No Signature X Title Date State of County of 20 Subscribed and sworn to before me the by (Print name of Signer) American LegalNet, Inc. www.FormsWorkFlow.com Notary Signature Nevada Secretary of State Exemption Declaration Revised: 1-5-15