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Form Fis 0565 - Statement Demonstrating Eligibility For Registration By Notification Page 2

Include all securities which will be outstanding if all the securities being offered or proposed to be offered are

issued, whether or not they are proposed to be registered or offered in this state.

6. State net earnings of the issuer and any predecessors during the past 3 fiscal years, determined in accordance with generally

accepted accounting practices which are applicable to all securities without a fixed maturity or a fixed interest or dividend

provision. (These must be figures pursuant to certified audit with evidence thereof attached.)

Net Earnings

Fiscal Year Ended

Total

Average (1/3)

5% of total in Question 4 is

5% of total in Question 5 is

If the Securities comply with Sec. 302(a)(2), then answer Question 7.

7. If this is a non-issuer distribution and is not being registered under Sec. 302(a)(1), then state

(a) if any security of this class has ever been previously registered under this act or a predecessor act. (Give details including

date.)

or (b) if the security being registered was originally issued pursuant to an exemption under this act or a predecessor act.

(Give details including date)

Signature of officer, member, partner, or proprietor

Title

Date

Form Fis 0565 - Statement Demonstrating Eligibility For Registration By Notification Page 2