Quarterly And Or Final Report Of Sales Of Security {QR}

SD EForm - 1436 V1 DIVISION OF SECURITIES STATE OF SOUTH DAKOTA Pierre, South Dakota 57501 QUARTERLY AND/OR FINAL REPORT OF SALES OF SECURITIES OUR FILE NUMBER:____________________________ DATE OF EFFECTIVE REGISTRATION:_______________ NAME OF ISSUER:_________________________________________________________________________________ DESCRIPTION OF ISSUE:___________________________________________________________________________ AGGREGATE DOLLAR AMOUNT REGISTERED IN SOUTH DAKOTA: $__________________________________ UNSOLD BALANCE AT THE BEGINNING OF REPORTING PERIOD: $____________________________________ AMOUNT REGISTERED THIS PERIOD: $_____________________________________________________________ TOTAL AVAILABLE FOR SALE THIS PERIOD: $_______________________________________________________ AMOUNT SOLD THIS REPORTING PERIOD: $_________________________________________________________ AMOUNT UNSOLD AT END OF THIS REPORTING PERIOD (balance): $___________________________________ RATIO OF COMMISSIONS AND UNDERWRITING EXPENSES TO AGGREGATE AMOUNT SOLD:___________ THIS REPORT COVERS THE PERIOD ENDING:________________________________________________________ COMPLETE THE BOTTOM PORTION OF THIS REPORT ONLY IF IT APPLIES: Please check the appropriate box ( ): () () Registration has been COMPLETED and no further offers or sales will be made in connection with this offering and sale of securities. It is requested that the unsold balance of $__________________________________ (aggregate dollar amount) be renewed for an additional period of one (1) year. In support of this request, we enclose the following: 1. Renewal fee of $100.00 payable to the South Dakota Division of Securities. 2. An updated prospectus containing a balance sheet and a profit and loss statement as of a date not more than ninety (90) days prior to the date of renewal. EXECUTED THIS_________________DAY OF____________________________, 20____ AT___________________ (Please type or print) _________________________________________ NAME OF ISSUER OR UNDERWRITER _________________________________________ SIGNATURE AND OFFICIAL CAPACITY American LegalNet, Inc. www.FormsWorkFlow.com