Form 133.30 - Information Concerning Projected Market Prices And Related Market Information - Texas State Securities Board Page 4

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Form
133.30
STATE OF
COUNTY OF
Before me, the undersigned authority, on this day personally appeared
(applicant), and having been duly sworn on oath deposes and says that the securities proposed to
be sold under this exemption are not a part of an unsold allotment or subscription in the
distribution of such securities by the Issuer; that securities of the same class, of the same issuer,
are outstanding in the hands of the public; that no part of the proceeds of such sale will be paid
directly or indirectly to the Issuer of such securities; that such sale is not directly or indirectly for
the purpose of providing or furthering any scheme to violate or evade any provision of the Texas
Securities Act; and that the Issuer of such securities is a going concern actually engaged in
business and is neither in an organizational stage nor in receivership or bankruptcy.
(Signature of Affiant)
(Capacity)
Subscribed and sworn to before me the _________ day of ____________________, 20 ______.
Notary Public in and for the County of
State of
(NOTARY SEAL)
My commission expires
08-16-2010

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