Form Se-1 - Statement Of Claim For The Exemption Of Securities Of A New Generation Processing Entity Page 3

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STATE OF _____________________________
}
ss.
County of ______________________________
The undersigned, __________________________________________________ , being first duly sworn, deposes and says:
That he has executed the foregoing statement of claim for and on behalf of the issuer named therein, that he is _____________
of such issuer and is fully authorized to execute and file such statement of claim; that he is familiar with such statement of claim; and
that to the best of his knowledge, information and belief the statements made in such statement of claim are true and the documents
submitted therewith are true copies of the originals thereof.
Name
Subscribed and sworn to before me, this
day of
, 20
,
(Notary Seal)
Notary Public
In and for the County of
State of
My Commission Expires:
FORM SE-1 (01-05)

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