STATE OF OHIO Telephone (614) 644-7381 File Number Department of Commerce Division of Securities 77 South High Street, Columbus, Ohio 43215-6131 Form 391 Registrant Must Not fill In. Division Record -- Date Checked By Notation Filing Fee Received Penalty Fee Received Record Made Accepted for Filing Not Eligible For Filing Prior Registration (Registrant Must Not Fill In.) (Section) (File) (Date) (Amount) (Description) (Price) (Amount) (Description) (Price) This Registration (Registrant Must Not Fill In.) (Section) 1. (File) (Date) Issuer's Name Payer’s Federal 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 registered 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 timely 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 Name of Issuer Number of Purchasers on those Dates Name (Printed) Signature Units Purchased Total Dollar Amount Title Date 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 checks payable to OHIO DIVISION OF SECURITIES, and send to 77 South High Street, 22nd Floor, Columbus, Ohio 43215-6131 Correspondence regarding this form should be sent to: COM 4543 (Rev. 2/05) American LegalNet, Inc. www.USCourtForms.com