Requirement Of Semi-Annual Report Form - Department Of Corporations State Of California (2013) Page 2
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1
2California Code of Regulations
Page 2 of 2
By____________________________
(Title)
I certify (or declare) under penalty of perjury under the laws of the State of California that I have
read this report and the exhibits thereto and know the contents thereof, and that the statements
therein are true and correct.
Executed at ____________________, on ________________, 20____.
(Place) (Date)
_______________________________
(Signature)
Instructions: The report should be signed by an officer or general partner of the issuer; however, it
may be signed by another person holding a power of attorney for such purposes from the issuer and,
if signed on behalf of the issuer pursuant to such power of attorney, should include as an additional
exhibit a copy of said power of attorney or a copy of the corporate resolution authorizing the person
to sign on behalf of the corporation.
07/03/13
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