Form 3-Q - Report Of Sale Of Securities (Page 2 of 3) in pdf

A section 1707.03(Q) claim of exemption is being made for the following securities sold in Ohio within 60 days of

the filing of this form and not previously reported (use additional sheet, if necessary):

Type of

Date of

Number of

Price

Number of

Securities Sold

Sale

Units Sold

per Unit

Purchasers

Note:

O.A.C. rule 1301:6-3-03(B)(5) deems a sale to have occurred on the later of: (a) the date that a subscription agreement or

its equivalent, signed by the purchaser, is received by the issuer or the dealer, or the purchaser transfers or loses control of

the purchase funds, whichever is earlier; or (b) the first date of disbursement of any proceeds of the sale of the securities

which have been deposited directly into an escrow account.

Confirm that the basis in law for this claim of exemption from Section 5 of the Securities Act of 1933 is pursuant to

Section 4(2) of that Act. Note that Rules 504, 505 and 506 cannot be used as a basis for claiming the exemption

pursuant to Section 1707.03(Q).

List the total number of persons who have purchased this offering to date, both in and outside of Ohio, including

persons claimed on all previous Form 3-Qs filed in connection with this offering.

(a)

List any commissions, discounts, or other remuneration paid or to be paid or given to any person, directly or

indirectly, for sales in Ohio of the securities claimed on the Form 3-Q (if none, please state “None”). Use

additional sheet if necessary.

Name and address of person

Amount of

Percentage of

receiving commission, etc.

commission, etc.

the Initial Offering Price

(b)

Were above commissions, discounts, or other remuneration paid or given only to dealers or salesmen licensed

 YES

 NO

under Chapter 1707 of the Revised Code?

Was an offering circular used in connection with the sales reported on this Form 3-Q?

 YES

 NO

 Copy attached or  Previously submitted

If yes,

 YES

 NO

10.

Has this offering been terminated?

If yes, date of termination

11.

Incorporated issuers not domiciled in this state or unincorporated issuers having a situs of its principal place of

business outside this state must file a Form 11 or Form U-2. (See section 1707.11, R.C.)

SIGNATURE

The undersigned represents that the foregoing information is true as of the date hereof and agrees that this report shall be

considered a written statement used for the purpose of selling securities in Ohio within the meaning of Section 1707.44(B)

of the Ohio Revised Code. The individual signing this report on behalf of the issuer further represents that he/she is duly

authorized by the issuer to execute and file this report.

Form 3-Q - Report Of Sale Of Securities Page 2

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