(INTERIM) COMMONWEALTH OF VIRGINIA STATE CORPORATION COMMISSION DIVISION OF SECURITIES AND RETAIL FRANCHISING AFFIDAVIT REGARDING OFFERS OF SCOR SECURITIES BY ISSUER AGENTS STATE OF ) ) ss County of ), I, , being first duly sworn on oath depose and say: I am now a citizen of the United States of America, over the age of twen ty-one and competent to be a witness. I am a bona fide officer [or director] of ________________________ (the issuer). I will provide each person to whom I offer securities with the form Consumers Guide to Small Business Investments, and I will obtain a dated receipt from each su ch investor. I understand that failure to comply with this requirement is grounds for revocation or suspension of my license. I understand that the license for which I am applying only authorizes me to offer and sell securities on behalf of ___________________________ (issuers name) and must be done pursuant to the registration statement on file with the Virginia State Corporation Commi ssion. I will not be receiving sales related compensation for the sale of the S COR securities. ________________________________ SUBSCRIBED AND SWORN to before me this ___ day of ___________, _____ ________________________________ Notary Public in and for the state of _________________, RESIDING AT American LegalNet, Inc. www.USCourtForms.com