Notice Under Section 207(J) Of The Pennsylvania Securities Act Of 1972 {207J}

FORM 207-J (Instruction Sheet) PENNSYLVANIA DEPARTMENT OF BANKING AND SECURITIES CORPORATION FINANCE OFFICE 17 N 2ND ST, STE 1300 Harrisburg, PA 17101-2290 (717) 787-8059 ***** Notice under section 207(J) of the Pennsylvania Securities Act of 1972 ("ACT") for continuation of an offering registered under Section 205 NOTE: Under Regulation 603.011, a document is not deemed filed with the Pennsylvania Department of Banking and Securities ("Department") unless complete and properly executed in all material respects. WHO MUST FILE: Issuers that want to extend the effective period of a Section 205 registration statement for an additional period of one year provided, however, that filing Form 207-J shall not extend the offering for a period beyond the three years from the initial effective date of the registration statement in this Commonwealth. Form 207-J may not be used if the issuer was required to file a new registration statement with the U.S. Securities and Exchange Commission. WHEN TO FILE: At the Department's Harrisburg office prior to the expiration of the currently effective period of registration of an offering of securities under Section 205. General Instructions 1. One copy of the Form and all attachments shall be filed with the Department. If mailed, it is advisable to send it by registered or certified mail, postage prepaid, return receipt requested. 2. Typewrite or print all answers in the space provided. Answer each item completely. An answer of "not applicable" is inappropriate. If the space is insufficient, attach a schedule to the Form and make reference in the Form to each item included in the schedule. 3. This Form shall be manually signed by the issuer. If the issuer is a corporation, it should be signed in the name of the corporation by an executive officer duly authorized; if a partnership, it should be signed in the name of the partnership by a general partner; and if an unincorporated association or other organization not a partnership, this Form should be signed in the name of such organization by a person responsible for the direction or management of its affairs. 4. Please remove this instruction sheet before filing this Form. EACH PERSON COMPLETING THIS FORM OR PROVIDING INFORMATION TO BE INCLUDED IN THIS FORM SHOULD BE FAMILIAR WITH THE PENALTIES CONTAINED IN THE ACT, AND ALL REGULATIONS ADOPTED THEREUNDER, FOR MAKING FALSE OR INCOMPLETE STATEMENTS IN CONNECTION WITH THE SALE OF A SECURITY OR IN ANY FILING WITH THE DEPARTMENT. FORM 207-J REVISED: 03/01/2016 1 American LegalNet, Inc. www.FormsWorkFlow.com PENNSYLVANIA DEPARTMENT OF BANKING AND SECURITIES CORPORATION FINANCE OFFICE NOTICE UNDER SECTION 207(J) OF THE PENNSYLVANIA SECURITIES ACT OF 1972 OF CONTINUATION OF SECTION 205 OFFERING 1. 2. Exact name of Issuer: Address of principal office of Issuer: Number and Street City 3. State Zip Code Telephone No. Name and address of person to whom correspondence regarding this filing should be sent: Name Title Number and Street City 4. State Zip Code Telephone No. (A) Initial effective date of registration statement in Pennsylvania: (B) Description of securities registered: (C) Department file number to which this request pertains: 5. The person executing this Form on behalf of the Issuer hereby affirms that: (a) Such person is familiar with the provisions of Section 207(j) under the Act and all regulations adopted thereunder, including Regulation 207.101 (b) The statements made in this Form, including all attachments hereto, are not incomplete in any material respect or false or misleading with respect to any material fact. Please be advised that all representations in this application are subject to the penalties of 18 Pa. C.S. §4904 (relating to unsworn falsification to authorities). Furthermore, your application will be considered a document filed with the Department of Banking and Securities for purposes of Section 407 of the 1972 Act, 70 P.S. §1-407. IN WITNESS WHEREOF, this Form has been duly executed (Insert Date) (Name of Issuer) (By) (Title) FORM 207-J REVISED: 03/01/2016 2 American LegalNet, Inc. www.FormsWorkFlow.com