THE STATE OF CALIFORNIA
Notice of Release of Securities from Escrow
Pursuant to Section 260.141.13 of the rules of the Commissioner of Corporations, you are hereby
notified that the securities formerly held by the undersigned in escrow pursuant to a permit issued, to
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dated ________________, 19____ (File No._______), have been released from escrow and delivered
to the following persons who are the record owners thereof:
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All such certificates delivered to such record owners contained the legend required by Section
260.141.11 of the Commissioner's rules. A copy of Section 260.141.11 of the Commissioner's rules has
been delivered to each record owner of the securities.
The undersigned has duly caused this notice to be executed on its behalf by the person signing the
same, who was duly authorized to do so.
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By________________________________
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(Title)
I certify (or declare) under penalty of perjury under the laws of the State of California that I have
read this notice and know the contents thereof, and that the statements therein are true and correct.
Executed at_________________, on_____________, 19________,
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(Signature)