Notice Of Exchange Transaction Or Entity Conversion Pursuant To Corporations Code Section 25103(H) - State Of California Commissioner Of Corporations Page 2

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__________________________________________________
Print Name and Title of Signatory
Name, Address and Phone Number of Contact Person:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Instructions: Each acquiring or converting entity (other than a California corporation) filing a
notice under Section 25103(h) must file a consent to service of process (Form 260.165), unless it
already has a consent to service on file with the Commissioner. 260.103.6 (9/09)
260.103.6(b) (Register No. 2009, No. 39)

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