Oklahoma Accredited Investor Exemption Supplemental Information Form OKLAHOMA DEPARTMENT OF SECURITIES 120 N. Robinson, Suite 860 Oklahoma City, OK 73102 (405) 280-7700 http://www.securities.state.ok.us The Oklahoma Accredited Investor Exemption ("OAIE") was originally a dopted by an order of the Administrator of the Oklahoma Department of Securities (the Department) on March 8, 19 99. Effective July 1, 2004, the OAIE is set forth in 660:11-11-52 of the Rules of the Oklahoma Securities Commission and the Administrator of the Department of Securities, a part of the Oklahoma Administrative Codes ("Rules"). 660:11-11-52 wa s finally adopted under the authority of Section 2- 103 of the Oklahoma Uniform Securities Act of 2004 (OUSA), also effect ive July 1, 2004. This form is supplemental to, and must be filed with the Department in addition to, the NASAA Model Ac credited Investor Exemption Uniform Notice of Transaction (the "Uniform Notice") by any person intending to rely upo n such exemption for offers and sales subject to OUSA. The notice must also include a consent to service of process [Form U-2 and (if applicable) Form U-2A], a copy of the general announcement as specified in the rule, and a fee as set fort h in Section 1-612.A.12 of OUSA. Such filing must be made no later than 15 days after the first sale of securities su bject to the OUSA. PART A 1. Issuer Name: 2. Type of Filing: New Filing AmendmentPART B Enter the information requested for the following: Each promoter of the issuer, if the issuer has been organized in the pas t five years; Each beneficial owner having power to vote or dispose, or direct the vot e or disposition of, 10% or more of a class of equity securities of the issuer; Each executive officer or director of corporate general and managing par tners of partnership issuers; Each executive officer or director of corporate managers of limited liab ility companies; Each individual general or managing partner of partnership issuers; and Each individual manager of limited liability company issuers. Check Box(es) that Apply: Promoter Beneficial Owner Executive Officer Director General or Managing Partner Manager Other (Explain) Full Name (Last name first, if individual): Company Name: Business or Residence Address (Number and Street, City, State, ZIP Code ): Phone: Explanation (if necessary): Check Box(es) that Apply: Promoter Beneficial Owner Executive Officer Director General or Managing Partner Manager Other (Explain) Full Name (Last name first, if individual): Company Name: Business or Residence Address (Number and Street, City, State, ZIP Code ): Phone: Explanation (if necessary): Check Box(es) that Apply: Promoter Beneficial Owner Executive Officer Director General or Managing Partner Manager Other (Explain) Full Name (Last name first, if individual): Company Name: Business or Residence Address (Number and Street, City, State, ZIP Code ): Phone: Explanation (if necessary): (Use blank sheet, or use additional copies of this sheet, as necessary. ) American LegalNet, Inc. www.USCourtForms.com>>>> 2PART C 1. What is the minimum investment that will be accepted from any purchas er?........................................................$2. Does the offering permit joint ownership of a single security?....... ...........................................YESNO PART D Enter the information requested for each person (other than any broker- dealer listed in the Uniform Notice or agents thereof) who has been or will bepaid or given, directly or indirectly, any commission or similar remuner ation for solicitation of purchasers in Oklahoma in connection with sale sof securities in the offering. Full Name (Last name first, if individual) Business or Residence Address (Number and Street, City, State, Zip Code ) Full Name (Last name first, if individual) Business or Residence Address (Number and Street, City, State, Zip Code ) Full Name (Last name first, if individual) Business or Residence Address (Number and Street, City, State, Zip Code ) Full Name (Last name first, if individual) Business or Residence Address (Number and Street, City, State, Zip Code ) (Use blank sheet, or copy and use additional copies of this sheet, as n ecessary.) PART E Jurisdictions in Which the Issuer Has Solicited or Intends to Solicit Pu rchasers (Check All Jurisdictions or check individual jurisdictions)....... ........................................................................ .......................................All Jurisdictions[AL] [AK] [AZ] [AR] [CA] [CO] [CT] [DE] [DC] [FL] [GA] [HI] [ID] [IL] [IN] [IA] [KS] [KY] [LA] [ME] [MD] [MA] [MI] [MN][MS] [MO] [MT] [NE] [NV] [NH] [NJ] [NM] [NY] [NC] [ND] [OH] [OK] [OR] [PA] [RI] [SC] [SD] [TN] [TX] [UT] [VT] [VA] [WA] [WV] [WI] [WY] [PR] The undersigned represents that the Issuer is familiar with the conditio ns that must be satisfied to be entitled to the OklahomaAccredited Investor Exemption and understands that the Issuer claiming t he availability of this exemption has the burden ofestablishing that these conditions have been satisfied. The undersigned, a duly authorized person to act on behalf of the issuer , has read this notification and knows the contents to be trueand has signed this notice on behalf of the issuer. Issuer (Print or Type) Signature Date Name (Print or Type) Title (Print or Type) [Adopted on March 9, 1999; Amended effectively July 1, 2004] American LegalNet, Inc. www.USCourtForms.com