Tennessee Department of Commerce and Insurance Division of Securities NOTICE OF SALE OF SECURITI ES PURSUANT T O ACCREDITED INVEST OR EXEMPTION 1. Issuer: Name: Address: Phone Number: 2. Form of Organization (Check One): Corporation Unincorporated Association Limited Liability Company Limited Partnership Other (Specify): Issuers state of Incorporation or jurisdiction or organization: Date of Incorporation or Organization: 3. Officers and Directors (or persons acting in a similar capacity): Name, Address, and Phone Number Capacity Page 1 of 4 American LegalNet, Inc. www.USCourtForms.com>>>> 2 (attach additional sheets if necessary) Page 2 of 4 American LegalNet, Inc. www.USCourtForms.com>>>> 3 4. This Offering: Description of Price per Number of Securities Aggregate Dollar Security Security to be Offered Amount Debt Equity (common or preferred) Convertible Security Partnership Interests Other (Specify) 5. Description of Business: 6. Name of Broker-Dealer who has solicited or intends to solicit purchasers in this state: Page 3 of 4 American LegalNet, Inc. www.USCourtForms.com>>>> 4 7. Submitted herewith as part of this notice are the following: (a) A copy of the general announcement (if one made regarding the proposed offering); (b) Consent to service of process; and (c) A non-refundable filing fee of five hundred dollars ($500). Execution and Certification By filing this Notice of Transaction, the Issuer of these securities hereby represents that: The undersigned represents that the Issuer is familiar with the conditions that must be satisfied to be entitled to the Accredited Investor Exemption of the state in which this notice is filed and understands that the Issuer claiming the availability of this exemption has the burden of establishing that these conditions have been satisfied; and. On the basis of representations, certifications or other evidence received from purchasers of securities in this offering, the Issuer believes that all such purchasers are accredited investors as defined in T.C.A. 48-2-102(16). The issuer has read this notification and knows the contents to be true and has duly caused this notice to be signed on its behalf by the undersigned duly authorized person. Issuer (Print or Type) Signature Name (Print or Type) Title (Print or Type) Date IN-1460 RDA 959 Page 4 of 4 American LegalNet, Inc. www.USCourtForms.com