STATE OF OHIO Department of Commerce File No. Division of Securities 77 South High Street, Columbus, Ohio 43215-6131 Form 6(A)(3) Registration for the sale of securities representing an interest in a general partnership, limited partnership, partnership association, limited liability company, syndicate, pool, trust, trust fund or other unincorporated association Telephone: (614) 644-7381 Registrant Must Not Complete. Division Record -- Date Checked By Notation Fee ($50.00) Received Prior registrations checked Examined as to form Amendment requested Accepted for filing Acknowledgment sent Registration withdrawn Registration suspended Registration refused Examination requested This Registration (Registrant Must Not Complete.) (Section) (File) (Date) (Price) (Amount) (Description) Note: Use this form only for registering an intended future sale of securities by an issuer (other than a corporation) pursuant to the provisions of R.C. Section 1707.06(A)(3). Separate forms must be obtained from the Division of Securities for registration pursuant to R.C. Sections 1707.06(A)(1), (2), or (4). If the space provided on this form is inadequate for full response, attach an exhibit numbered to correspond to the number of the question thereby answered. Integration: The issuer should be aware that all sales of securities before or after this filing may be subject to integration with this offering by the Division. Factors considered particularly relevant to integration include: 1) Are the offerings part of a single plan of financing? 2) Do the offerings involve issuance of the same class of security? 3) Are the offerings made at or about the same time? 4) Is the same type of consideration to be received? 5) Are the offerings made for the same general purpose? COMPLETE ALL ITEMS 1. Form of business organization of issuer: (e.g., general partnership, limited partnership, partnership association, limited liability company, syndicate, pool, trust fund or other association.) 2. Issuer's name: (Payer's Federal Tax Identification Number) 3. Issuer's principal business office: (Street and Number) 4. (City, State, Zip) (Phone) Date and state of issuer's organization: (Month, Day and Year) COM 4592 (Rev. 2/05) (State) American LegalNet, Inc. www.USCourtForms.com 5. (a) Statutory agent: (b) If applicant is an issuer having the situs of its principal place of business outside Ohio, attach a Form 11 or a Form U-2. 6. State specifically the actual business in which issuer is engaged or will engage: 7. State the names and addresses of the general partners, principals, managers, trustees or other persons who are charged with the management of the organization: 8. List all similar enterprises in which the issuer or its principals are engaged: 9. Described securities (a) Authorized to be issued: (b) Now issued and outstanding: 10. (a) The securities to be registered for sale in Ohio are as follows: (Describe each class to be sold): (Number) (Class) (Price per unit) (Aggregate sale price) (Number) (Class) (Price per unit) (Aggregate sale price) (b) State the maximum period of time during which the securities will be offered (Not to exceed sixteen months): 11. Will these securities be sold exclusively for cash? ❏ YES ❏ NO If not, attach an exhibit stating: (1) what will be received for such securities; (2) the number and class of securities to be exchanged therefore; (3) the name and addresses of the persons who will receive such securities; and (4) a sworn appraisal by a qualified, disinterested, non-affiliated appraiser or such other proof as may be available as to the true value of such consideration. Designate as Exhibit 11. 12. (a) Will these securities be sold to not more than a maximum of thirty-five purchasers? (Note: The following shall not be included among the thirty-five purchaser maximum: (a) any purchaser of at least $100,000 of the securities offered hereby; (b) any general partner, trustee, director, or executive officer of the issuer or any member in a limited liability company, if the issuer is a limited liability company in which the management is reserved to its members or manager of a limited liability company, if the issuer is a limited liability company in which the management is not reserved to its members.) (b) Will the aggregage commission, discount or other remuneration, excluding legal, accounting, and printing fees, paid or given direcly or indirectly in connection with the sale of these securities exceed ten per cent of the initial offering price? American LegalNet, Inc. www.USCourtForms.com 13. Attach the following required Exhibits. (State if a provision below is not applicable.) A. Attach a final draft of the organizational agreement executed or to be executed. Designate this Exhibit 13-A. B. Attach a prospectus if the aggregate amount of this offering exceeds $250,000. Designate this Exhibit 13-B. C. Attach a copy of the issuer's financial statement, either audited or attested to by an executive officer, for the most recent fiscal year and the most recent fiscal quarter. Designate this Exhibit 13-C. D. Attach an exhibit describing use of proceeds. Designate this Exhibit 13-D. E. Attach a copy of all printed material to be used in connection with the sale of securities including, but not limited to advertising, offering circulars, business plans and projections, marketing and financial analysis, and any other literature. Designate as Exhibit 13– E. F. Attach a specimen of security to be sold. Designate as Exhibit 13-F. G. If issuer is not domiciled in Ohio, attach Form 11. (R.C. Section 1707.11.) 14. Correspondence and the Certificate of Acknowledgment for this registration should be addressed to: Name City, State, Zip Street and Number Phone Fax SIGNATURE This form must be signed in the name of the issuer, i.e., general partnership, limited partnership, syndicate, pool, trust or other association, limited liability company, and by the general partner, principal, manager, trustee, or other person or persons charged with the management of this enterprise. Issuer _______________________________ By _______________________________ (Title) By _______________________________ (Title) VERIFICATION (Verification by One Person is Sufficient) County of State of The undersigned, sworn, deposes and says: being first duly That he has executed the foregoing for, and on behalf of, the applicant named therein; that he is of such applicant and is fully authorized to execute and file such application; that he is familiar with such application and the facts underlying such application; and that to the best of his knowledge, information and belief, the statements made in such application are true and the documents submitted herewith are true copies of the original thereof. Signature of Person Sworn Office Held Month, Day and Year Subscribed and sworn to before me Signature of Notary Public A Certificate of Acknowledgment will be mailed at effectiveness in seven business days pursuant to R.C. Section 1707.08 if the registration by description is not suspended or refused pursuant to R.C. Sections 1707.13 and 1707.131. No form can be returned for correction, nor can a refund be made of filing fees. Submit completed registration together with $50.00 fee to Division of Securities, 77 South High Street, Floor 22, Columbus, Ohio 432156131. American LegalNet, Inc. www.USCourtForms.com