NY FORM RI-1 NEW YORK STATEDEPARTMENT OF LAWINVESTOR PROTECTION BUREAU, 2 FloorNew York, NY 11-800-771-7755 TDD (for hearing impaired) 1-800-788-9898www.ag.ny.gov REGISTRANT INFORMATION FORM1.Last Name First Name Middle Name2.Business Address Street City State Zip Code3. 4(a). 4(b). Place of Birth Date of Birth Business Phone5.Name of Issuer: 6.Have you ever used or been known by any other name?Yes [ ] No [ ]If 223Yes224, please specify7.Have you or has any business entity under your control or in which you were a principal shareholder(10% or more) or in which you held a substantial equity or controlling interest (10% or more) or ofwhich you were an officer, director, general partner, trustee or principal:(a) ever been convicted of any crime (other than minor traffic violations) or is any such charge presently pending:Yes [ ] No [ ](b) ever been the subject of any injunction, cease and desist order, assurance of discontinuance, suspension or restraining order, revocation of a license to practice a trade, occupation or profession, denial of an application to obtain or renew same, any stipulation or consent to desist from any act or practice, any disciplinary action by any court or administrative agency, or is any action or proceeding seeking such relief presently pending?Yes [ ] No [ ](c) ever made an assignment for the benefit of creditors, been the subject of a receivership or bankruptcy proceeding, reorganized in bankruptcy, or been adjudged a bankrupt?Yes [ ] No [ ](d) ever had a judgment entered against you or have a judgement which is presently unsatisfied?Yes [ ] No [ ]8.Are you or is any business entity under your control or in which you were a principal shareholder(10% or more) or in which you held a substantial equity or controlling interest (10% or more) orof which you were an officer, director, general partner, trustee or principal, a party in any litigationor administrative proceeding in which it is alleged that you or it committed fraud or otherwiseviolated any provision of the Martin Act or any other securities law?Yes [ ] No [ ]9.If the answer to 7(a) through (d), or 8 is "Yes" state full particulars, including dates, nature ofproceeding, title and location of public authority, circumstances and final disposition. If thereis insufficient space below, complete response in an attached, sworn statement.10.List all professional, business or occupational licenses or registrations which you now hold, have held, or have applied for: IP RI-1() Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 11.The following is my complete employment and business record including periods of self-employment and unemployment for thepast five years:FromToName and Address of EmployerType ofBusinessPosition Held Mo. Yr. Mo. Yr. 12.The following is a complete record of my business affiliations for the past five years, including all entities not listed in 11 above,under my control or in which I was a principal shareholder (10% or more) or in which I held a substantial equity or controllinginterest (10% or more) or of which I was an officer, director, general partner, trustee or principal.FromToName and Address of EntityType ofBusinessPosition Held Mo. Yr. Mo. Yr. Date: Signature: STATE OF ) : SS.: COUNTY OF ), being duly sworn, deposes and says that I am the person described in and whosigned the above registrant information form. I have read the questions and answers and information supplied, and they are true, accurateand complete. (Signature of Affiant)Sworn to before me this day of , 20.(Notary signature and legible official stamp) President or General Partner IP RI-1 /) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com