Form Sr-2 - Annual Report For Renewal Of Registration Of Securities Page 2

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Date___________________________________
(CORPORATE SEAL)
__________________________________________________
Name of Issuer
By _______________________________________________
Name and Title
Print
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STATE OF _____________________________
}
ss.
County of ______________________________
The undersigned, __________________________________________________ , being first duly sworn, deposes and says:
That he has executed the foregoing report for and on behalf of the issuer named therein, that he is _______________________
of such issuer and is fully authorized to execute and file such report; that the statements made in the report, including all attachments
thereto, are not false in any material respect or misleading with respect to any material fact.
__________________________________________________
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 SR-2 (01-05)

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