State Notice And Further State Notice {DOS-125-f-l}

NYS DEPARTMENT OF STATE STATE RECORDS ONE COMMERCE PLAZA 99 WASHINGTON AVENUE ALBANY, NY 12231-0001 This form constitutes TWO DISTINCT NOTICES, each of which must be filed in DUPLICATE. A fee of $75 must accompany each State Notice and each Further State Notice. Checks, money orders and bank drafts should be made payable to Department of State; amounts over $500 must be paid by money order, bank draft or certified check. Mail completed form and fee to State Records at the above address. Please do not send cash through the mail. DO NOT send offering literature to the Secretary of State. State Notice Under §359-e, subd. 2 of the General Business Law of the State of New York (FEE: $75 / State Notice. This notice must be filed by every security broker or dealer prior to engaging in the business of selling or offering for sale securities to the public in the State of New York.) NAME OF DEALER OR BROKER LIST BUSINESS OR POST OFFICE ADDRESS and "X" TYPE BELOW "X" ONE { BUSINESS ADDRESS POST OFFICE/MAILING ADDRESS IF A CORPORATION, STATE OR COUNTRY IN WHICH INCORPORATED IF A PARTNERSHIP, THE NAMES OF THE GENERAL PARTNERS Further State Notice Under §359-e, subd. 8 of the General Business Law of the State of New York (FEE: $75 / Further State Notice. This notice to be filed for each issue to be offered, except those specifically exempted by §359-f.) NAME OF DEALER, BROKER OR SYNDICATE MANAGER LIST BUSINESS OR POST OFFICE ADDRESS and "X" TYPE BELOW "X" ONE { BUSINESS ADDRESS POST OFFICE/MAILING ADDRESS IF A CORPORATION, STATE OR COUNTRY IN WHICH INCORPORATED NAME OF SECURITY OR SECURITIES (CLASS) NAME OF ISSUER OF SECURITIES MAIL ADDRESS FOR ISSUER OF SECURITIES (i.e., POSTAL ADDRESS) STATE OR COUNTRY IN WHICH ORGANIZED DOS-0125-f-l (Rev. 07/11) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com NEW YORK STATE DEPARTMENT OF STATE Instructions for Filing State and Further State Notices Please be sure to check these areas before submitting State Notices and Further State Notices . Fees · The filing fee for a State Notice (top portion of the form) is $75.00. · The filing fee for a Further State Notice (bottom portion of the form) is $75.00. · If submitting both a State Notice and a Further State Notice (top and bottom portion of the form) the filing fee is $150.00. There is no additional fee for the duplicate copy(ies). State Notice (Top portion of form; must be filed in duplicate) · Provide the name and address of the Dealer OR Broker. After registering as a Dealer or a Broker, you may act as a Syndicate Manager and file a Further State Notice as such. However, for the purposes of the State Notice, you act as either a Dealer or a Broker. · If a corporation, indicate the state or country in which incorporated. If a partnership, leave the incorporation line blank and enter the names of the partners in the (next) section provided. · ONLY ONE NAME is permitted per State Notice; e.g., if a Dealer and Broker will both be involved, two separate State Notices are required. If an exemption has been granted, please state such in the State Notice portion of the form. · A State Notice is a one-time filing unless there has been a name or address change. Further State Notice (Bottom portion of form; must be filed in duplicate) · · · · · · Be sure that whomever you list as the Dealer, Broker AND/OR Syndicate Manager has a prior State Notice on file with the New York State Department of State as a Dealer or Broker. Provide the name and address for each Dealer, Broker and/or Syndicate Manager. If a corporation, indicate the state or country in which incorporated. If more than one Dealer, Broker or Syndicate Manager is involved, list the names, addresses and where incorporated for each. List the class form of security to be offered. We cannot accept multiple classes on one Further State Notice unless they are preceded by "Units consisting of ..." or "Common stock with warrants," etc. Please be advised that the word "and" denotes multiple filings. Also, do not list Fund names as classes of securities; we need to know what (in the fund) is being offered; i.e., "Shares of Beneficial Interest," etc. Provide the Issuer's name and address as well as where organized. Only ONE Issuer name is permitted per Further State Notice. Combination State and Further State Notice · If submitting a State Notice for a Dealer or Broker who will be offering the securities for the Issuer named on the Further State Notice, the names must match exactly on both forms; e.g., do not list the Broker as "ABC Fund" on the State Notice and "ABC Fund/ABC Senior Managed Portfolio" on the Further State Notice. DOS-0125-f-l (Rev. 07/11) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com