File Number NEW YORK STATE DEPARTMENT OF LAW INVEST PROTECTION BUREAU, 2FloorNew York, NY 101-800-771-7755 TDD (for hearing impaired) www.ag.ny.gov (Found on fee receipt for original filing) ISSUER STATEMENT(Section 359-e General Business Law) Issuer NamePrincipal Office Address City State Zip CodeTelephone Number Note: This form should not to be used by issuers engaged in any aspect of unless they also obtain aletter upon written application pursuant to General Business Law Section 352-e or 352-g. Theatrical Syndication must comply with Article23 of the Arts and Cultural Affairs Law. Contact the Real Estate Finance Bureau regarding Intrastate offerings pursuant to 247 359-ff.1.Issuer is an existing or a proposed 001 corporation; 001 general partnership; 001 limited partnership;001other (specify) organized under the laws of on .2.The business of the issuer is (describe briefly): 3.Issuer proposes to offer: 001 stock; 001 bonds; 001 notes; 001 partnership interests; 001 other (specify)4.The securities will be sold: 001 by the partner(s), officer(s), director(s) or principal(s) of the issuer; 001 by salespeople employed byissuer.The securities will be sold on a best efforts basis? G Yes G No. If no, please explain.5.Total amount of offering $ ; 001 offering literature attached; 001 if not available, attach a letter of explanation.Total anticipated offering expenses $ consisting of: Selling: $ ; Other: $ .6.State use of the net proceeds to be obtained: Please indicate where the fee receipt should be sent:[ ] Attorney [ ] IssuerAttorney or Issuer NameStreet AddressCity State ZipFiling Fee for Issuer Statement as follows:If total amount of offering is $500,000 or less......... Fee is $ 300If total amount of offering is more than $500,000... Fee is $ 1,200Make check payable to the NYS Department of Law.Payment by Attorney's check, company check, certified check, bankcheck or money order. Personal checks not accepted. Send remittance to: Invest Protection Bureau NYS Department of Law, 2 FloorNew York, New York 10 IP M-11 () American LegalNet, Inc. www.FormsWorkFlow.com 7.Any secondary offering of securities by selling holders of the issuer, please check box G.Indicate the details of the secondary offering below for each seller.Name of Seller Address Anticipated Dollar Amount Offered8.Has registrant, any officer, director or principal or partner ever...A.been suspended or expelled from membership in any securities or commoditiesexchange, association of securities or commodities dealers or investment advisers?Yes [ ]No [ ]B.had a license or registration as a dealer, broker, investment adviser or sales person,futures commission merchant, associated person, commodity pool operator, orcommodity trading advisor denied, suspended or revoked? ....................................Yes [ ]No [ ]C.been enjoined or restrained by any court or government agency from:1.the issuance, sale or offer for sale of securities or commodities?.....................Yes [ ]No [ ]2.rendering securities or commodities advice?....................................................Yes [ ]No [ ]3.handling or managing trading accounts? .........................................................Yes [ ]No [ ]4.continuing any practices in connection with securities or commodities?..........Yes [ ]No [ ]D.been convicted of any crime (other than minor traffic)? .........................................Yes [ ]No [ ]E.used or been known by any other name? ................................................................Yes [ ]No [ ]F.been the subject of any professional disciplinary proceeding, hearing, settled complaints or arbitrations in excess of $10,000? ...................................................Yes [ ]No [ ]G.been adjudged a bankrupt or made a general assignment for the benefit of creditors; or beenan officer, director or principal of any entity which was reorganized in bankruptcy,adjudged a bankrupt or made a general assignment for the benefit of creditors? .........Yes [ ]No [ ]H.had an offering of securities within the last the three years or been an officer, director, partner of any entity which had an offering of securities within the last three years .......................................................................................................Yes [ ]No [ ]I.9.Are there any outstanding judgments (not including judgments involving domesticrelations) against the issuer or any officer, director, principal or partner thereof?.........Yes [ ]No [ ]10.List names or CRD Numbers of all employees (excluding officers and directors) of Issuer who are selling in New York State.A Form U4 must be submitted for each salesperson listed.Name of Employee CRD Number 11.Limited Partnerships are required to submit a list of all limited partners as soon as the offering is completed. This maybe done in letter form.12.If the Issuer is a limited partnership list all of the general partners. IPM-1() Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 13.For each officer, director, principal, partner or managing member, please provide the information requested. In the case of a corporategeneral partner information must be provided for all officers. Do not refer to a prospectus or offering literature. SEC biographies can besubstituted for employment history only. If additional space is necessary, please attach additional pages. Social security numbers andresidential information are strictly confidential.a.Name: Title: Address: Prior home addresses for the past 5 years:Telephone: Social Security #: Date of Birth: Place of Birth:List employment and business affiliation record for the past five years. (Indicate periods of self-employment and unemployment.Include all corporations or other entities where individual holds or held a substantial equity or controlling interest). From Mo./ Yr. To Mo./ Yr. Employer or Business Affiliation NameAddress Position Held and Type of Businessb.Name: Title: Address: Prior home addresses for the past 5 years:Telephone: Social Security #: Date of Birth: Place of Birth:List complete employment and business affiliation record for the past five years. (Indicate periods of self-employment and unemployment.Include all corporations or other entities where individual holds or held a substantial equity or controlling interest). From Mo./ Yr. To Mo./ Yr. Employer or Business Affiliation NameAddress Position Held and Type of Business IP M-11 () Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 13.Continuedc.Name: Title: Address: Prior home addresses for the past 5 years:Telephone: Social Security #: Date of Birth: Place of Birth:List complete employment and business affiliation record for the past five years. (Indicate periods of self-employment and unemployment.Include all corporations or other entities where individual holds or held a substantial equity or controlling interest). From Mo./ Yr. To Mo./ Yr. Employer or Business Affiliation NameAddress Position Held and Type of Business If all signatures are not available at time of filing, you must submit the proper total fee andall information required by item 13. One original signature is required at the time of filing. Note in your letter that counterpart forms withmissing signatures will be submitted within 30 days of filing.Limited Partnerships, Limited Liability Corporations and Limited Liability Partnerships must supply one signature for each general partner ormanaging member. One signature by an officer of a corporate general partner or managing member is sufficient, however, all selling officersmust sign.All officers, directors, partners, controlling principals, or managing members of the registrant listed in Item 13, provide an original signaturebelow. All statements contained herein are true and correct and each individual understands that any false statement shall constitute a violationof Art. 23-A of the General Business Law. Name and Title (please type or print) Signature Date IP M-11() Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com