Model Accredited Investor Exemption Uniform Notice Of Transaction

SD EForm - 1435 V1 MODEL ACCREDITED INVESTOR EXEMPTION UNIFORM NOTICE OF TRANSACTION NOTICE OF SALE OF SECURITIES PURSUANT TO ACCREDITED INVESTOR EXEMPTION ______________________________________________________________________________ 1. Issuer Name: ___________________________________________________________________ Address: ___________________________________________________________________ Phone #: ___________________________________________________________________ ______________________________________________________________________________ 2. Form of Organization (Check One) [ ] Corporation [ ] Unincorporated Association [ ] Limited Liability Company [ ] Limited Partnership [ ] Other (Specify) _______________________________________ Issuer's state of Incorporation or jurisdiction or organization ________ Date of Incorporation or Organization _____________ ______________________________________________________________________________ 3. Officers and Directors (or persons acting in a similar capacity) Names, Address, and Phone Numbers: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ _____________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 4. This offering: Description of Security: [ | Debt [ ] Partnership interest [ ] Equity (common or preferred) [ ] Convertible security [ ] Other (specify) _______________________________________ Number of securities to be offered ________________________________________________ Aggregate dollar amount _______________________________________________________ ______________________________________________________________________________ 5. Description of business: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ _____________________________________________________________________________ By filing this Notice of Transaction, the Issuer of these securities hereby represents that: The Issuer is familiar with the conditions that must be satisfied to be entitled to the Accredited Investor Exemption of the state in which this notice is filed and understands that the Issuer claiming the availability of this exemption has the burden of establishing that these conditions have been satisfied. The issuer has read this notification and knows the contents to be true and has duly caused this notice to be signed on its behalf by the undersigned duly authorized person. Issuer __________________________________________________ (print or type) Name __________________________________________________ (print or type) Signature _______________________________________________ Title ________________ (print or type) Date _______________ American LegalNet, Inc. www.FormsWorkFlow.com