Waiver Request For Exempt Securities Transactions {08-116}

Department of Commerce, Community & Economic Development Division of Banking & Securities, Securities Section P.O. Box 110807 Juneau, AK 99811-0807 Telephone: (907) 465-2521 Email: dbsc@alaska.gov Waiver Request for Exempt Securities Transactions (To be filed along with the fee required by 3 AAC 08.920(a)(6)) Under AS 45.55.900(b)(9) This form is provided for use by a person to request a waiver from the division for a non-issuer transaction that is subject to AS 45.55.900(b)(9). The request for waiver is required to be filed because the person is a promoter as defined by 3 AAC 08.950(16) or controlling person as defined by 3 AAC 08.910(14), effective March 4, 2015. Filing must be accompanied by the fee required by 3 AAC 08.920(a)(6). 1. Name, Address, and Telephone number of contact person filing this notice: Full Name Address Phone Fax The person signing this form must show name & address above. If different from the contact person, show information on signe. The E-mail address given must show the address to send the order of effectiveness. 2. A. Name, Address, and Telephone number of Non-Issuer (Seller) requesting exemption: Name of Non-Issuer (Seller) Address Phone B. Name, Address, and Telephone number of issuer subject to the transaction: Name of Issuer Address Phone 3. Formed as an Alaska domestic (Corporation, LP, LLP, or LLC) under Alaska Statutes Title 10 or Title 32. 4. Please provide a brief description of the terms of the seller's transaction (including security and price), and the basis of the seller's request for the Administrator to waive the promoter or controlling person provision. Yes No If more space is needed, please add a page or include attachments. 5. Date sales expected to commence: 08-116 Rev. 01/16 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com I understand, under AS 45.55.160, it is UNLAWFUL to file with the Administrator of Securities any document that would make, or cause to be made, an untrue statement of material fact or omit to state a material fact necessary so as to make the statement made not misleading. Signature of attorney or principal ( please describe which) Title Date E-mail address: Additional space for explanation (Please refer to paragraph number being amplified): For Office Use only American LegalNet, Inc. www.FormsWorkFlow.com 08-116 Rev. 01/16 Page 2 of 2