Form SEC1972 Form D -Notice of Exempt Offering of Securities

Securities and Exchange Commission

FORM D

OMB APPROVAL
OMB APPROVAL

Washington, DC 20549

Notice of Exempt
Offering of Securities

OMB Number: 3235-0076

Expires:
April 30, 2023
Estimated average burden
Intentional misstatements or omissions of fact constitute federal criminal violations. See 18 U.S.C. 1001.
hours per response:
4.00

(See instructions beginning on page 5)

Item 1. Issuer's Identity
Name of Issuer

Previous Name(s)

None

Entity Type (Select one)
Corporation
Limited Partnership

Jurisdiction of Incorporation/Organization

Limited Liability Company
General Partnership
Business Trust

Year of Incorporation/Organization

Other (Specify)

(Select one)
Within Last Five Years
(specify year)

Over Five Years Ago

Yet to Be Formed

(If more than one issuer is filing this notice, check this box

and identify additional issuer(s) by attaching Items 1 and 2 Continuation Page(s).)

Item 2. Principal Place of Business and Contact Information
Street Address 1

Street Address 2

City

State/Province/Country

ZIP/Postal Code

Phone No.

Item 3. Related Persons
Last Name

Middle Name

First Name
Street Address 2

Street Address 1
State/Province/Country

City

Relationship(s):

Executive Officer

Director

ZIP/Postal Code

Promoter

Clarification of Response (if necessary)
(Identify additional related persons by checking this box

Item 4. Industry Group

Agriculture
Banking and Financial Services

Business Services
Energy

Commercial Banking

Electric Utilities

Insurance

Energy Conservation

Investing

Coal Mining

Investment Banking

Environmental Services

Pooled Investment Fund
If selecting this industry group, also select one fund
type below and answer the question below:
Hedge Fund

Oil & Gas
Other Energy

Health Care

Biotechnology

Private Equity Fund

Health Insurance

Venture Capital Fund

Hospitals & Physicians

Other Investment Fund

Pharmaceuticals

Is the issuer registered as an investment
company under the Investment Company
Yes
No
Act of 1940?

Other Health Care

Other Banking & Financial Services

SEC1972 (5/17)

and attaching Item 3 Continuation Page(s). )

(Select one)

Manufacturing
Real Estate
Commercial

Construction
REITS & Finance
Residential
Other Real Estate

Retailing
Restaurants
Technology
Computers
Telecommunications
Other Technology

Travel

Airlines & Airports

Lodging & Conventions
Tourism & Travel Services
Other Travel

Other
Form D 1

FORM D

U.S. Securities and Exchange Commission
Washington, DC 20549

Item 5. Issuer Size

(Select one)

Revenue Range (for issuer not specifying "hedge"
or "other investment" fund in Item 4 above)

Aggregate Net Asset Value Range (for issuer
specifying "hedge" or "other investment" fund in
Item 4 above)
No Aggregate Net Asset Value

OR

No Revenues
$1 - $1,000,000

$1 - $5,000,000

$1,000,001 - $5,000,000

$5,000,001 - $25,000,000

$5,000,001 - $25,000,000

$25,000,001 - $50,000,000

$25,000,001 - $100,000,000

$50,000,001 - $100,000,000

Over $100,000,000

Over $100,000,000

Decline to Disclose

Decline to Disclose

Not Applicable

Not Applicable

Item 6. Federal Exemptions and Exclusions Claimed

(Select all that apply)

Investment Company Act Section 3(c)

Rule 504(b)(1) (not (i), (ii) or (iii))

Section 3(c)(1)

Section 3(c)(9)

Rule 504(b)(1)(i)

Section 3(c)(2)

Section 3(c)(10)

Section 3(c)(3)

Section 3(c)(11)

Section 3(c)(4)

Section 3(c)(12)

Section 3(c)(5)

Section 3(c)(13)

Section 3(c)(6)

Section 3(c)(14)

Rule 504(b)(1)(ii)
Rule 504(b)(1)(iii)
Rule 506(b)
Rule 506(c)
Securities Act Section 4(a)(5)

Section 3(c)(7)

Item 7. Type of Filing
New Notice

OR

Amendment

Date of First Sale in this Offering:

First Sale Yet to Occur

OR

Item 8. Duration of Offering
Yes

Does the issuer intend this offering to last more than one year?

Item 9. Type(s) of Securities Offered

No

(Select all that apply)

Equity

Pooled Investment Fund Interests

Debt

Tenant-in-Common Securities

Option, Warrant or Other Right to Acquire
Another Security

Mineral Property Securities
Other (describe)

Security to be Acquired Upon Exercise of Option,
Warrant or Other Right to Acquire Security

Item 10. Business Combination Transaction
Is this offering being made in connection with a business combination
transaction, such as a merger, acquisition or exchange offer?

Yes

No

Clarification of Response (if necessary)

Form D 2

FORM D

U.S. Securities and Exchange Commission
Washington, DC 20549

Item 11. Minimum Investment
Minimum investment accepted from any outside investor

$

Item 12. Sales Compensation
Recipient

Recipient CRD Number
No CRD Number
(Associated) Broker or Dealer CRD Number

None

(Associated) Broker or Dealer

No CRD Number
Street Address 2

Street Address 1

State/Province/Country

City

All States
AZ
IA

AR
KS

Foreign/Non-US
CA
CO
KY
LA

NV
SD

NH
TN

NJ
TX

States of Solicitation

AL
IL
MT
RI

AK
IN
NE
SC

NM
UT

ZIP/Postal Code

CT
ME

DE
MD

NY
VT

NC
VA

DC
MA
ND
WA

(Identify additional person(s) being paid compensation by checking this box

FL
MI

GA
MN

HI
MS

OH
WV

OK
WI

OR
WY

ID
MO
PA
PR

and attaching Item 12 Continuation Page(s).)

Item 13. Offering and Sales Amounts
(a) Total Offering Amount
(b) Total Amount Sold
(c) Total Remaining to be Sold
(Subtract (a) from (b))

$

OR

Indefinite

OR

Indefinite

$
$

Clarification of Response (if necessary)

Item 14. Investors
Select if securities in the offering have been or may be sold to persons who do not qualify as accredited investors, and enter the number of
such non-accredited investors who already have invested in the offering:
Regardless of whether securities in the offering have been or may be sold to persons who do not qualify as accredited investors, enter the
total number of investors who already have invested in the offering:

Item 15. Sales Commissions and Finders' Fees Expenses
Provide separately the amounts of sales commissions and finders' fees expenses, if any. If the amount of an expenditure is not known,
provide an estimate and check the box next to the amount.

Clarification of Response (if necessary)

Sales Commissions $

Estimate

Finders' Fees $

Estimate

Form D 3

FORM D

U.S. Securities and Exchange Commission
Washington, DC 20549

Item 16. Use of Proceeds
Provide the amount of the gross proceeds of the offering that has been or is proposed to be
used for payments to any of the persons required to be named as executive officers,
directors or promoters in response to Item 3 above. If the amount is unknown, provide an
estimate and check the box next to the amount.

Estimate

$

Clarification of Response (if necessary)

Signature and Submission
Please verify the information you have entered and review the Terms of Submission below before signing and submitting this notice.

Terms of Submission. In Submitting this notice, each issuer named above is:
Notifying the SEC and/or each State in which this notice is filed of the offering of securities described and
undertaking to furnish them, upon written request, in accordance with applicable law, the information furnished to offerees.*
Irrevocably appointing each of the Secretary of the SEC and the Securities Administrator or other legally designated officer of
the State in which the issuer maintains its principal place of business and any State in which this notice is filed, as its agents for service of
process, and agreeing that these persons may accept service on its behalf, of any notice, process or pleading, and further agreeing that
such service may be made by registered or certified mail, in any Federal or state action, administrative proceeding, or arbitration brought
against the issuer in any place subject to the jurisdiction of the United States, if the action, proceeding or arbitration (a) arises out of any
activity in connection with the offering of securities that is the subject of this notice, and (b) is founded, directly or indirectly, upon the
provisions of: (i) the Securities Act of 1933, the Securities Exchange Act of 1934, the Trust Indenture Act of 1939, the Investment
Company Act of 1940, or the Investment Advisers Act of 1940, or any rule or regulation under any of these statutes; or (ii) the laws of the
State in which the issuer maintains its principal place of business or any State in which this notice is filed.
Certifying that, if the issuer is claiming a Regulation D exemption for the offering, the issuer is not disqualified from relying on
Rule 504 or Rule 506 for one of the reasons stated in Rule 504(b)(3) or Rule 506(d).
* This undertaking does not affect any limits Section 102(a) of the National Securities Markets Improvement Act of 1996 ("NSMIA") [Pub. L. No.
104-290,110 Stat. 3416 (Oct. 11, 1996)] imposes on the ability of States to require information. As a result, if the securities that are the subject of this Form
D are"covered securities" for purposes of NSMIA, whether in all instances or due to the nature of the offering that is the subject of this Form D, States
cannot routinely require offering materials under this undertaking or otherwise and can require offering materials only to the extent NSMIA permits
them to doso under NSMIA's preservation of their anti-fraud authority.

Each issuer identified above has read this notice, knows the contents to be true, and has duly caused this notice to be signed on its
behalf by the undersigned duly authorized person. (Check this box
and attach Signature Continuation Pages for signatures of
issuers identified in Item 1 above but not represented by signer below.)

Issuer(s)

Name of Signer

Signature

Title

Date
Number of continuation pages attached:
Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB
number.
Form D 4

FORM D

U.S. Securities and Exchange Commission
Washington, DC 20549

Instructions for Submitting a Form D Notice
3. Related
Persons (continued)
l Instructions
General
Who must file: Each issuer of securities that sells
its securities in reliance on an exemption
provided in Regulation D or Section 4(a)(5) of
the Securities Act of 1933 must file this notice
containing the information requested with the
U.S. Securities and Exchange Commission (SEC)
and with the state(s) requiring it. If more than
one issuer has sold its securities in the
same transaction, all issuers should be identified
in one filing with the SEC, but some states may
require a separate filing for each issuer or
security sold.
When to file:
o An issuer must file a new notice with the SEC
for each new offering of securities no later than
15 calendar days after the "date of first sale" of
securities in the offering as explained in the
Instruction to Item 7. For this purpose, the date of
first sale is the date on which the first investor is
irrevocably contractually committed to invest,
which, depending on the terms and conditions
of the contract, could be the date on which the
issuer receives the investor's subscription
agreement or check. An issuer may file the
notice at any time before that if it has
determined to make the offering. An issuer must
file a new notice with each state that requires it at
the time set by the state. For state filing
information, go to www.NASAA.org. A
mandatory capital commitment call does not
constitute a new offering, but is made under the
original offering, so no new Form D filing is
required.
o An issuer may file an amendment to a
previously filed notice at any time.
o An issuer must file an amendment to a
previously filed notice for an offering:
- to correct a material mistake of fact or
error in the previously filed notice, as soon
as practicable after discovery of the mistake
or error;
- to reflect a change in the information
provided in the previously filed notice,
except as provided below, as soon as
practicable after the change; and

When amendment is not required: An issuer
is not required to file an amendment to a
previously filed notice to reflect a change that
occurs after the offering terminates or a change
that occurs solely in the following information:
- the address or relationship to the issuer of
a related person identified in response to
Item 3;
- an issuer's revenues or aggregate net
asset value;
- the minimum investment amount, if the
change is an increase, or if the change,
together with all other changes in that
amount since the previously filed notice,
does not result in a decrease of more than
10%;

Saturdays, Sundays and holidays: If the date
on which a notice or an amendment to a
previously filed notice is required to be filed falls
on a Saturday, Sunday or holiday, the due date is
the first business day following.
Amendment content: An issuer that files an
amendment to a previously filed notice must
provide current information in response to all
items of this Form D, regardless of why the
amendment is filed.
How to file: Issuers must file this notice with
the SEC in electronic format. For state filing
information, go to www.NASAA.org.

- any address or state(s) of solicitation
shown in response to Item 12;
- the total offering amount, if the change is
a decrease, or if the change, together with
all other changes in that amount since the
previously filed notice, does not result in an
increase of more than 10%;
- the amount of securities sold in the
offering or the amount remaining to be
sold;
- the number of non-accredited investors
who have invested in the offering, as long as
the change does not increase the number to
more than 35;
- the total number of investors who have
invested in the offering; and

Filing fee: There is no federal fiing fee. For
information on state filing fees, go to www.
NASAA.org.
Definitions of terms: Terms used but not
defined in this form that are defined in Rule 405
and Rule 501 under the Securities Act of 1933,
17 CFR 230.405 and 230.501, have the
meanings given to them in those rules.

- the amount of sales commissions, finders'
fees or use of proceeds for payments to
executive officers, directors or promoters, if
the change is a decrease, or if the change,
together with all other changes in that
amount since the previously filed notice,
does not result in an increase of more than
10%.

- annually, on or before the first anniversary
of the most recent previously filed notice, if
the offering is continuing at that time.

Form D 5

FORM D
Item-by-Item Instructions
Item 1. Issuer's Identity. Identify each legal entity issuing any securities being reported as being offered by entering its full name; any
previous name used within the past five years; and its jurisdiction of incorporation or organization, type of legal entity, and year of
incorporation or organization within the past five years or status as formed over five years ago or not yet formed. If more than one entity is
issuing the securities, identify a primary issuer in the first fields shown on the first page of the form, checking the box provided, and identify
additional issuers by attaching Items 1 and 2 continuation page(s).
Item 2. Principal Place of Business and Contact Information. Enter a full street address of the issuer's principal place of business. Post
office box numbers and "In care of" addresses are not acceptable. Enter a contact telephone number for the issuer. If you identified more
than one issuer in response to Item 1, enter the requested information for the primary issuer you identified in response to that item and, at
your option, for any or all of the other issuers you identified on your Item 1 and 2 continuation page(s).
Item 3. Related Persons. Enter the full name and address of each person having the specified relationships with any issuer and identify
each relationship:
• Each executive officer and director of the issuer and person performing similar functions (title alone is not determinative) for the
issuer, such as the general and managing partners of partnerships and managing members of limited liability companies; and
• Each person who has functioned directly or indirectly as a promoter of the issuer within the past five years of the later of the first sale
of securities or the date upon which the Form D filing was required to be made.
If necessary to prevent the information supplied from being misleading, also provide a clarification in the space provided.
Identify additional persons having the specified relationships by checking the box provided and attaching Item 3 continuation page(s).
Item 4. Industry Group. Select the issuer's industry group. If the issuer or issuers can be categorized in more than one industry group,
select the industry group that most accurately reflects the use of the bulk of the proceeds of the offering. For purposes of this filing, use the
ordinary dictionary and commonly understood meanings of the terms identifying the industry group.
Item 5. Issuer Size.
• Revenue Range (for issuers that do not specify "Hedge Fund" or "Other Investment Fund" in response to Item 4): Enter the revenue range
of the issuer or of all the issuers together for the most recently completed fiscal year available, or, if not in existence for a fiscal year, revenue
range to date. Domestic SEC reporting companies should state revenues in accordance with Regulation S-X under the Securities Exchange
Act of 1934. Domestic non-reporting companies should state revenues in accordance with U.S. Generally Accepted Accounting Principles
(GAAP). Foreign issuers should calculate revenues in U.S. dollars and state them in accordance with U.S. GAAP, home country GAAP or
International Financial Reporting Standards. If the issuer(s) declines to disclose its revenue range, enter "Decline to Disclose." If the
issuer's(s') business is intended to produce revenue but did not, enter "No Revenues." If the business is not intended to produce revenue
(for example, the business seeks asset appreciation only), enter "Not Applicable."
• Aggregate Net Asset Value (for issuers that specify "Hedge Fund" or "Other Investment Fund" in response to Item 4): Enter the aggregate
net asset value range of the issuer or of all the issuers together as of the most recent practicable date. If the issuer(s) declines to disclose its
aggregate net asset value range, enter "Decline to Disclose."
Item 6. Federal Exemption(s) and Exclusion(s) Claimed. Select the provision(s) being claimed to exempt the offering and resulting sales
from the federal registration requirements under the Securities Act of 1933 and, if applicable, to exclude the issuer from the definition of
"investment company" under the Investment Company Act of 1940. Select "Rule 504(b)(1) (not (i), (ii) or (iii))" only if the issuer is relying on
the exemption in the introductory sentence of Rule 504 for offers and sales that satisfy all the terms and conditions of Rules 501 and 502(a),
(c) and (d).
Item 7. Type of Filing. Indicate whether the issuer is filing a new notice or an amendment to a notice that was filed previously. If this is a
new notice, enter the date of the first sale of securities in the offering or indicate that the first sale has "Yet to Occur." For this purpose, the
date of first sale is the date on which the first investor is irrevocably contractually committed to invest, which, depending on the terms and
conditions of the contract, could be the date on which the issuer receives the investor's subscription agreement or check.
Item 8. Duration of Offering. Indicate whether the issuer intends the offering to last for more than one year.

Form D 6

FORM D
Item-by-Item Instructions (Continued)
Item 9. Type(s) of Securities Offered. Select the appropriate type or types of securities offered as to which this notice is filed. If the
securities are debt convertible into other securities, however, select "Debt" and any other appropriate types of securities except for "Equity."
For purposes of this filing, use the ordinary dictionary and commonly understood meanings of these categories. For instance, equity
securities would be securities that represent proportional ownership in an issuer, such as ordinary common and preferred stock of
corporations and partnership and limited liability company interests; debt securities would be securities representing money loaned to an
issuer that must be repaid to the investor at a later date; pooled investment fund interests would be securities that represent ownership
interests in a pooled or collective investment vehicle; tenant-in-common securities would be securities that include an undivided fractional
interest in real property other than a mineral property; and mineral property securities would be securities that include an undivided
interest in an oil, gas or other mineral property.
Item 10. Business Combination Transaction. Indicate whether or not the offering is being made in connection with a business
combination, such as an exchange (tender) offer or a merger, acquisition, or other transaction of the type described in paragraph (a)(1), (2)
or (3) of Rule 145 under the Securities Act of 1933. Do not include an exchange (tender) offer for a class of the issuer's own securities. If
necessary to prevent the information supplied from being misleading, also provide a clarification in the space provided.
Item 11. Minimum Investment. Enter the minimum dollar amount of investment that will be accepted from any outside investor. If the
offering provides a minimum investment amount for outside investors that can be waived, provide the lowest amount below which a
waiver will not be granted. If there is no minimum investment amount, enter "0." Investors will be considered outside investors if they are
not employees, officers, directors, general partners, trustees (where the issuer is a business trust), consultants, advisors or vendors of the
issuer, its parents, its majority owned subsidiaries, or majority owned subsidiaries of the issuer's parent.
Item 12. Sales Compensation. Enter the requested information for each person that has been or will be paid directly or indirectly any
commission or other similar compensation in cash or other consideration in connection with sales of securities in the offering, including
finders. Enter the CRD number for every person identified and any broker and dealer listed that has a CRD number. CRD numbers can be
found at http://brokercheck.finra.org. A person that does not have a CRD number need not obtain one in order to be listed, and must be
listed when required regardless of whether the person has a CRD number. In addition, check the State(s) in which the named person has
solicited or intends to solicit investors. If more than five persons to be listed are associated persons of the same broker or dealer, enter only
the name of the broker or dealer, its CRD number and street address, and the State(s) in which the named person has solicited or intends to
solicit investors.
Item 13. Offering and Sales Amounts. Enter the dollar amount of securities being offered under a claim of federal exemption identified in
Item 6 above. Also enter the dollar amount of securities sold in the offering as of the filing date. Select the "Indefinite" box if the amount
being offered is undetermined or cannot be calculated at the present time, such as if the offering includes securities to be acquired upon
the exercise or exchange of other securities or property and the exercise price or exchange value is not currently known or knowable. If an
amount is definite but difficult to calculate without unreasonable effort or expense, provide a good faith estimate. The total offering and
sold amounts should include all cash and other consideration to be received for the securities, including cash to be paid in the future under
mandatory capital commitments. In offerings for consideration other than cash, the amounts entered should be based on the issuer's good
faith valuation of the consideration. If necessary to prevent the information supplied from being misleading, also provide a clarification in
the space provided.
Item 14. Investors. Indicate whether securities in the offering have been or may be sold to persons who do not qualify as accredited
investors as defined in Rule 501(a), 17 CFR 230.501(a), and provide the number of such investors who have already invested in the
offering. In addition, regardless of whether securities in the offering have been or may be sold to persons who do not qualify as accredited
investors, specify the total number of investors who already have invested.
Item 15. Sales Commission and Finders' Fees Expenses. The information on sales commissions and finders' fees expenses may be given
as subject to future contingencies.
Item 16. Use of Proceeds. No additional instructions.
Signature and Submission. An individual who is a duly authorized representative of each issuer identified must sign, date and submit this
notice for the issuer. The capacity in which the individual is signing should be set forth in the "Title" field underneath the individual's name.
The name of the issuer(s) on whose behalf the notice is being submitted should be set forth in the "Issuer" field beside the individual's
name; if the individual is signing on behalf of all issuers submitting the notice, the word "All" may be set forth in the "Issuer" field. Attach
signature continuation page(s) to have different individuals sign on behalf of different issuer(s). Enter the number of continuation pages
attached and included in the filing. If no continuation pages are attached, enter "0".

Form D 7

FORM D

U.S. Securities and Exchange Commission
Washington, DC 20549

Items 1 and 2 Continuation Page
Item 1 and 2. Issuer's Identity and Contact Information (Continued)
Name of Issuer

Previous Name(s)

None

Entity Type (Select one)
Corporation
Limited Partnership

Jurisdiction of Incorporation/Organization

Limited Liability Company
General Partnership
Business Trust

Year of Incorporation/Organization
(Select one)
Over Five Years Ago

Other (Specify)
Within Last Five Years
(specify year)

Yet to Be Formed

At your option, supply separate contact information for this issuer:
Street Address 2

Street Address 1

City

State/Province/Country

Previous Name(s)

Name of Issuer

ZIP/Postal Code

None

Phone No.

Entity Type (Select one)
Corporation
Limited Partnership

Jurisdiction of Incorporation/Organization

Limited Liability Company
General Partnership

Year of Incorporation/Organization

Business Trust

(Select one)
Over Five Years Ago

Within Last Five Years
(specify year)

Other (Specify)

Yet to Be Formed

At your option, supply separate contact information for this issuer:
Street Address 1

Street Address 2

City

State/Province/Country

Name of Issuer

Previous Name(s)

ZIP/Postal Code

None

Phone No.

Entity Type (Select one)
Corporation

Jurisdiction of Incorporation/Organization

Limited Partnership
Limited Liability Company
General Partnership

Year of Incorporation/Organization
(Select one)
Over Five Years Ago

Business Trust

Within Last Five Years
(specify year)

Yet to Be Formed

Other (Specify)

At your option, supply separate contact information for this issuer:
Street Address 2

Street Address 1

City

State/Province/Country

ZIP/Postal Code

Phone No.

(Copy and use additional copies of this page as necessary.)
Form D 8

FORM D

U.S. Securities and Exchange Commission
Washington, DC 20549

Item 3 Continuation Page
3. Related
Persons
(continued)
Item
3. Related
Persons
(Continued)

Street Address 2

Street Address 1
State/Province/Country

City

Relationship(s):

Middle Name

First Name

Last Name

Executive Officer

Director

ZIP/Postal Code

Promoter

Clarification of Response (if necessary)

Last Name

First Name

Street Address 2

Street Address 1
State/Province/Country

City

Relationship(s):

Middle Name

Executive Officer

Director

ZIP/Postal Code

Promoter

Clarification of Response (if necessary)

First Name

Last Name

Street Address 1

Street Address 2

City

Relationship(s):

Middle Name

State/Province/Country

Executive Officer

Director

ZIP/Postal Code

Promoter

Clarification of Response (if necessary)

First Name

Last Name

Street Address 2

Street Address 1
State/Province/Country

City

Relationship(s):

Middle Name

Executive Officer

Director

ZIP/Postal Code

Promoter

Clarification of Response (if necessary)
(Copy and use additional copies of this page as necessary.)
Form D 9

U.S. Securities and Exchange Commission

FORM D

Washington, DC 20549

Item 12 Continuation Page
3. Related
Persons
(continued)
Item
12. Sales
Compensation
(Continued)

Recipient

Recipient CRD Number
No CRD Number
None

(Associated) Broker or Dealer

(Associated) Broker or Dealer CRD Number
No CRD Number
Street Address 2

Street Address 1

State/Province/Country

City

States of Solicitation

AL
IL
MT
RI

AK
IN
NE
SC

All States
AZ
IA
NV
SD

AR
KS
NH
TN

CA
KY
NJ
TX

Foreign/Non-US
CO
CT
LA
ME
NM
NY
VT
UT

Recipient

ZIP/Postal Code

DE
MD
NC
VA

DC
MA
ND
WA

FL
MI
OH
WV

GA
MN
OK
WI

HI
MS
OR
WY

ID
MO
PA
PR

Recipient CRD Number
No CRD Number
None

(Associated) Broker or Dealer

(Associated) Broker or Dealer CRD Number
No CRD Number
Street Address 2

Street Address 1
City

State/Province/Country

States of Solicitation

AL
IL

AK
IN

All States
AR
AZ
IA
KS

MT
RI

NE
SC

NV
SD

NH
TN

Foreign/Non-US
CA
CO
CT
KY

LA

NJ
TX

NM
UT

ZIP/Postal Code

ME

DE
MD

DC
MA

FL
MI

GA
MN

HI
MS

ID
MO

NY
VT

NC
VA

ND
WA

OH
WV

OK
WI

OR
WY

PA
PR

(Copy and use additional copies of this page as necessary.)
Form D 10

FORM D

U.S. Securities and Exchange Commission
Washington, DC 20549

Signature Continuation Page
3. Relatedand
Persons
(continued)
Signature
Submission
The undersigned is the duly authorized representative of the issuer(s), identied in the field beside the individual's name below.
Issuer

Name of Signer

Signature

Title

Date

Issuer

Name of Signer

Signature

Title

Date

Issuer

Name of Signer

Signature

Title

Date

Issuer

Name of Signer

Signature

Title

Date

(Copy and use additional copies of this page as necessary.)
Form D 11