Annual Report Form (Intrastate) - New York State Department Of Law Page 2

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9. During the period covered by this report, was any injunction, cease an desist order, or revocationof
license or registration, obtained, or were any such actions or proceedings instituted, or were criminal
proceedings of any nature instituted or convictions obtained against the issuer or any principal thereof?
Yes [ ] No [ ]
10. If there is any additional information which is material, such as any change in the issuer's
management, ownership, financial structure, business, or its main operating location(s), or affirmative
answers to questions 6, 7B or 9, state details on a separate sheet. Is such sheet attached? Yes [ ] No [ ]
Date:_______________________________________________
By: ________________________________________________
Signature
(title)
Printed Name & Title:____________________________________
Telephone Number (include Area Code):______________________
TO: N.Y. STATE DEPT. OF LAW
REAL ESTATE FINANCING BUREAU
120 BROADWAY
NEW YORK, NY 10271

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