Form 391 File Number Registrant Must Not fill In. DIVISION RECORD Date Checked By Notation Filing Fee Received Penalty Fee Received Record Made Accepted for Filing Not Eligible f or Filing Prior R egistration (Registrant Must Not Fill In.) (Section) (File) (Date) (Amount) (Description) (Price) This Registration (Registrant Must Not Fill In.) (Section) (File) (Date) (Amount) (Description) (Price) 1. Issuer's Name eral Tax Identification Number 2. Issuer's Address 3. Attach a notarized statement from issuer or counsel using the following language regarding harm to the investors: "No purchaser or offeree of the securities sought to be exempted, qualified or r egistered pursuant to Section 1707.391 of the Revised Code was prejudiced by the failure to timely or properly exempt, qualify, or register the securities." 4. Attach a notarized statement from the issuer or counsel stating the reason for failure to time ly or properly file, and the number of times during the preceding twelve months the issuer has filed a Form 391. 5. Indicate number of Ohio purchasers of Securities to be qualified by completing the following. Dates of Original Sales From To Number of Purchasers on those Dates Units Purchased Total Dollar Amount Name of Issuer Name (Printed) Title Signature Date Division of Securities 77 South High Street 22 nd Floor Columbus, Ohio 43215 C OM 4543 4/11 /19 An Equal Opportunity Employer and Service Provider 614 - 644 - 7381 Fax : 614 - 728 - 2846 Investor Protection Hotline: 877 - 683 - 7841 TTY/TDD : 800 - 750 - 0750 com.ohio.gov American LegalNet, Inc. www.FormsWorkFlow.com Oh io Department of Commerce FORM 391 THE 391 FILING MUST INCLUDE A COPY OF THE APPROPRIATE FORM THAT IS TO BE CORRECTED, THE NOTARIZED STATEMENTS, AND PAYMENT OF THE REQUIRED FEE IF NOT ALREADY PAID, PLUS A PENALTY FEE EQUAL TO SUCH REQUIRED FEE. Make ch ecks payable to OHIO DIVISION OF SECURITIES, and send to 77 South High Street, 22 nd Floor, Columbus, Ohio 43215 - 6131. Correspondence regarding this form should be sent to : COM 45 43 4/11/19 American LegalNet, Inc. www.FormsWorkFlow.com