Report On Sales Of Securities {209}

FORM 209 (Instruction Sheet) PENNSYLVANIA DEPARTMENT OF BANKING AND SECURITIES CORPORATION FINANCE OFFICE 17 N 2ND ST, STE 1300 HARRISBURG, PA 17101-2290 (717) 787-8059 ***** REPORT ON SALES OF SECURITIES GENERAL INSTRUCTIONS WHO MUST FILE: Issuers with an effective registration statement for the offer and sale of securities in this Commonwealth under Section 206 which have NOT paid the maximum fee specified in Section 602 (b.1)(iii). WHEN TO FILE: File Form 209 within 420 days after the effective date of the registration statement in Pennsylvania. 1. For a further explanation of terms used in the Form, refer to Section 102 of the Pennsylvania Securities Act of 1972 ("1972 Act"). 2. One manually signed copy of the Form with all attachments shall be filed with the Pennsylvania Department of Banking and Securities ("Department"). If mailed, it is advisable to send it by registered or certified mail, postage prepaid, return receipt requested. 3. 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 to each item included in the schedule. 4. The Form filed with the Department must 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. 5. In the event that, at any time after the filing of the Form, the issuer becomes aware that any information provided on the Form becomes inaccurate in any material respect, the issuer shall file an amendment with the Department within 5 business days from the date the issuer became aware that the information previously submitted was inaccurate at the time it was filed. 6. In lieu of answering any specific question in the Form, the issuer may incorporate by reference information contained in any document attached thereto or previously on file with the Department. 7. Please remove instruction sheet before filing this Form. FORM 209 REVISED: 03/01/2016 1 American LegalNet, Inc. www.FormsWorkFlow.com File No. COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA DEPARTMENT OF BANKING AND SECURITIES CORPORATION FINANCE OFFICE PART I Issuer Information 1. Exact Name of Issuer: 2. Address of Principal Office of Issuer: Number and Street City Telephone No. State ZIP Code FORM 209 3. Name and address of person to whom correspondence regarding this filing should be sent: Name City Telephone No. Title State ZIP Code Number and Street PART II Report of Sales of Securities Registered under Section 206. 4. Date of effectiveness of registration statement under Section 206 5. (A) Offering in Pennsylvania: (i) Total number of shares or other units: (ii) Per share or unit price: (iii)Maximum aggregate offering price: (B) Sales in Pennsylvania: (i) Number of shares or other units: (ii) Aggregate proceeds received: FORM 209 REVISED: 03/01/2016 2 American LegalNet, Inc. www.FormsWorkFlow.com Each of the persons executing this report on behalf of the Issuer hereby affirms that the statements made herein, including all attachments hereto, are not incomplete in any material respect or false or misleading with respect to any material fact. Each of such persons further affirms that he is familiar with the penalties contained in the Pennsylvania Securities Act of 1972, and all regulations adopted thereunder for making any false or incomplete statement in connection with the sale of a security or in any filing with the Pennsylvania Department of Banking and Securities. 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 report has been executed on (insert date) (Name of Issuer) By: Title: FORM 209 REVISED: 03/01/2016 3 American LegalNet, Inc. www.FormsWorkFlow.com