Form 133.16 Texas State Securities Board P.O. Box 13167 Austin, Texas 78711-3167 Texas Crowdfunding Portal Withdrawal of Registration 1. Date the Texas crowdfunding portal ("portal") ceased business or the Applicant withdrew its registration request: 2. Location of Books and Records after Registration Withdrawal. Complete the following information for the location at which the portal will keep books and records after withdrawing its registration: Name of the Custodian of Records: Contact person: Address: Telephone Number: Email: 3. This is (check one): G one of the portal's other business locations or affiliates. G a third-party unaffiliated recordkeeper. G other. 4. If this address is a private residence, check this box: G 5. Briefly describe the books and records kept at this location: 6. Is the portal now the subject of or named in any investment-related: a. Investigation? b. Investor initiated complaint? c. Private civil litigation? Execution The undersigned hereby represents that he/she has executed this form on behalf of the Texas crowdfunding portal ("portal") or Applicant named below and that all information contained herein, including any 11-17-2014 American LegalNet, Inc. www.FormsWorkFlow.com G Yes G Yes G Yes G No G No G No Form 133.16 attachments hereto, is current, accurate and complete. The undersigned and portal further represent that the portal's books and records will hereinafter be preserved and available for inspection by the Securities Commissioner as required by law. (Name of Texas Crowdfunding Portal or Applicant) By: (Signature) (Print name and title) Subscribed and sworn to before me this _____ day of ___________________, 20_____. Notary Public in and for the County of State of My commission expires 11-17-2014 American LegalNet, Inc. www.FormsWorkFlow.com