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Affidavit Regarding Offers Of Scor Securities By Issuer Agents Form - Commonwealth Of Virginia

(INTERIM)

COMMONWEALTH OF VIRGINIA

STATE CORPORATION COMMISSION

DIVISION OF SECURITIES AND RETAIL FRANCHISING

AFFIDAVIT REGARDING OFFERS OF SCOR SECURITIES BY ISSUER

AGENTS

STATE OF

)

County of

, being first duly sworn on oath depose and say:

I am now a citizen of the United States of America, over the age of twenty-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 such 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 ___________________________ (issuer’s name) and must be done pursuant to the

registration statement on file with the Virginia State Corporation Commission.

I will not be receiving sales related compensation for the sale of the SCOR securities.

________________________________

SUBSCRIBED AND SWORN to before

me this ___ day of ___________, _____

________________________________

Notary Public in and for the state of

_________________, RESIDING AT

Affidavit Regarding Offers Of Scor Securities By Issuer Agents Form - Commonwealth Of Virginia