(Rev. 01/10) FORM X SMALL OFFERINGS BY ISSUERS WITH LOCAL OPERATIONS NOTICE OF CLAIM OF EXMPTION UNDER SECTION 58-13C-202X, NMSA 1978 TO: DIRECTOR, SECURITIES DIVISION STATE OF NEW MEXICO Notice is hereby given that the undersigned Company (corporation, limited partnership, limited liability company or limited liability partnership), claiming the exemption afforded by Section 58-13C-202X, NMSA 1978, intends to avail itself of said exemption with respect to offers and sales of its securities as hereinafter set forth. In support therefore, it submits the following information and exhibits: A. GENERAL INFORMATION 1. Name and mailing address of Company. 2. Type of entity (corporation, limited partnership, limited liability company, limited liability partnership or other). 3. Date and place of creation (incorporation, organization, filing or date of partnership agreement). 4. Term of entity (if applicable). 5. Purpose or investment objective of business. 6. Address where books and records, stock certificates or capital accounts are kept and by whom. 7. Name, address and telephone number of person who should be contacted about this notice. B. INFORMATION ABOUT THE OFFERING 1. Type of security, number of shares or units to be offered. 2. Offering price per share or unit. 3. Aggregate Offering Price. 4. Name and address of, and compensation to be received by, each person who will be effecting or attempting to effect sales of securities. 5. If monies from sales of securities are to be escrowed until a certain amount is raised attach a copy of the escrow agreement showing name and address of the escrow bank. American LegalNet, Inc. www.FormsWorkFlow.com 6. 7. General description of property, including location, in which such proceeds are to be invested. 8. Is the issuer, underwriter, or their affiliates subject to the disqualification in 12.11.12.11.C NMAC 9. C. General description of use of proceeds. Attach a copy of the prospectus or offering memorandum describing the offering which will be utilized to offer the securities and comply with the disclosure requirements set forth in 12.11.12.11.E NMAC and attach a copy of all advertising or promotional literature. GOVERNING INSTRUMENTS Attach a copy of the Articles of Incorporation, Articles of Organization, Registration of Limited Liability Partnership, Certificate of Limited Partnership or other instruments of creation of the Company, including all amendments. ___________________ Date ____________________________________ Name of Company ____________________________________ Signature and Title of Authorized Person ACCEPTANCE OF THIS NOTICE FOR FILING DOES NOT CONSTITUTE ANY APPROVAL OR RECOMMENDATION WHATSOEVER BY THE DIRECTOR OF THE NEW MEXICO SECURITES DIVISON OF THE SECURITIES TO BE ISSUED OR SOLD. American LegalNet, Inc. www.FormsWorkFlow.com