Report Of Sale Of Securities {3Q}

Form 3 - Q Report of Sale of Securities 1707.03(Q) File Number Claimant Must Not fill In. DIVISION RECORD ONLY Date Checked By Notation Fee ($100/$50) Received Prior filings checked Examined as to form Amendmen t Requested Accepted for Filing Record Made Examination Requested Exemption 3 - Q (Claimant Must Not Fill In ) . (File) (Date) (Amount) (Description) (Price) Note: Use this form to claim a section 1707.03(Q) exemption for securities sold in Ohio within 60 days of the filing of this form and not previously reported. Only those issuers relying on Section 4(2) of the Securities Act of 1933 are eligible to use this exemption. The non - refundable filing fee is $1 00 for the first filing and $50 for any subsequent related Form 3 - Q filing made during the same calendar year . Submit to the Ohio Division of Securities, 77 South High Street , 22 nd Floor, Columbus, Ohio 4 3215 - 6131 the following: (1) the completed Form 3 - 1. Issuer's full name ( ) 2. Issuer's Address (City, State, Zip) (Phone No.) 3. State of incorporation/formation T ype of entity (Corporation, Partnership, etc.) Division of Securities 77 South High Street 22 nd Floor Columbus, Ohio 43215 COM 459 6 4 /1 1 /19 An Equal Opportunity Employer and Service Provider 614 - 644 - 7381 Fax : 614 - 728 - 2846 Investor Protection Hotline: 877 - 683 - 7841 TTY/TDD : 800 - 750 - 0750 com.ohio.gov American LegalNet, Inc. www.FormsWorkFlow.com Ohio Department of Commerce FORM 3 - Q 4. Correspondence regarding this report should be sent to: (Name) (Street) (City, State, Zip Code) (Phone No.) 5. A section 1707.03(Q) claim of e xemption is being made for the following securities sold in Ohio within 60 days of the filing of this form and not previously reported (use additional sheet, if necessary): Type of Securities Sold Date of Sale Number of Units Sold Price per Unit Numb er of Purchasers Note: O.A.C. rule 1301:6 - 3 - 03(B)(5) deems a sale to have occurred on the later of: (a) the date that a subscription agreement or its equivalent, signed by the purchaser, is received by the issuer or the dealer, or the purchaser transfers or loses control of the purchase funds, whichever is earlier; or (b) the first date of disbursement of any proceeds of the sale of the securities which have been deposited directly into an escrow account. 6. Confir m that the basis in law for this claim of exemption from Section 5 of the Securities Act of 1933 is pursuant to Section 4(2) of that Act. Note that Rules 504, 505 and 506 cannot be used as a basis for claiming the exemption pursuant to Section 1707.03(Q). 7. List the total number of persons who have purchased this offering to date, both in and outside of Ohio, including persons claimed on all previous Form 3 - Qs filed in connection with this offering. 8. (a) List any commissions, discounts, or other remuneration paid or to be paid or given to any person, directly or indirectly, for sales in Ohio of the securities claimed on the Form 3 - Q (if none, please Name and address of person receiving co mmission, etc. Amount of commission, etc. Percentage of the Initial Offering Price (b) Were above commissions, discounts, or other remuneration paid or given only to dealers or salesmen licensed under Chap ter 1707 of the Revised Code? YES NO 9. Was an offering circular used in connection with the s ales reported on this Form 3 - Q? YES NO If yes, Copy attached or Previously submitted American LegalNet, Inc. www.FormsWorkFlow.com Ohio Department of Commerce FORM 3 - Q 10. Has this offering be en terminated? YES NO If yes, date of termination 11. Incorporated issuers not domiciled in this state or unincorporated issuers having a situs of its principal place of business outside this state must file a Form 11 or Form U - 2. (See sectio n 1707.11, R.C.) SIGNATURE The undersigned represents that the foregoing information is true as of the date hereof and agrees that this report shall be considered a written statement used for the purpose of selling securities in Ohio within the meanin g of Section 1707.44(B) of the Ohio Revised Code. The individual signing this report on behalf of the issuer further represents that he/she is duly authorized by the issuer to execute and file this report. Issuer or Dealer (Full Name) By (Signatur e) (Date) (Name) (Official Capacity) The Division suggests Form 3 - Q be sent certified mail for verification of receipt or send a copy of this form together with a self - addressed, stamped envelope . COM 459 6 Updated 4/11/19 American LegalNet, Inc. www.FormsWorkFlow.com