Model Accredited Investor Exemption Uniform Notice Of Transaction

MODEL ACCREDITED INVESTOR EXEMPTION UNIFORM NOTICE OF TRANSACTION NOTICE OF SALE OF SECURITIES PURSUANT TO ACCREDITED INVESTOR EXEMPTION ______________________________________________________________________________ 1. Issuer Name: Address: Phone Number: 2. ____________________________________________________ ____________________________________________________ ____________________________________________________ ______________________________________________________________________________ Form of Organization (Check One) ( ) Corporation ( ) Unincorporated Association ( ) Other (Specify) ( ) Limited Liability Company __________________________ ( ) Limited Partnership Issuer's state of Incorporation or jurisdiction or organization _______________________ Date of Incorporation or Organization _________________________________________ ______________________________________________________________________________ 3. Officers and Directors (or persons acting in a similar capacity) Names, Addresses, and Phone Numbers: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ______________________________________________________________________________ 4. This Offering: Description of Security Price per security Number of securities to be offered Aggregate dollar amount Debt Equity (common or preferred) Convertible Security Partnership Interests Other (Specify) 5. Description of business: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com ______________________________________________________________________________ 6. Name of Broker-Dealer who has solicited or intends to solicit purchasers in this state. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ______________________________________________________________________________ Business Address ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ______________________________________________________________________________ By filing this Notice of Transaction, the issuer of these securities hereby represents that: (1) (2) Sales of securities shall be made only to accredited investors as defined in 17 CFR 230.501(a). The issuer is not an issuer in the development stage that either has no specific business plan or purpose or has indicated that its business plan is to engage in a merger or acquisition with an unidentified company or companies, or other entity or person. The issuer reasonably believes that all purchasers are purchasing for investment and not with the view to or for sale in connection with a distribution of the security. Any resale of a security sold in reliance on this exemption within 12 months of sale, except a resale to an accredited investor or pursuant to a registration statement effective under applicable state securities law, shall be presumed to be with a view to distribution and not for investment. Securities issued under this exemption may only be resold pursuant to registration or an exemption under applicable state securities law. (3) The undersigned represents that the issuer is familiar with the conditions that must be satisfied to be entitled to the Accredited Investor Exemption of the state in which this notice is filed and understands that the issuer claiming the availability of this exemption has the burden of establishing that these conditions have been satisfied. The issuer has read this notification and knows the contents to be true and has duly caused this notice to be signed on its behalf by the undersigned duly authorized person. Issuer (Print or Type) Signature Date Name (Print or Type) Title (Print or Type) Note: Completion of this form does not relieve the filer of the obligation to ascertain and comply with any additional state requirements that may apply, such as consent to service of process, payment of requisite fees, and filing of copies of any general announcement of the proposed offering. American LegalNet, Inc. www.FormsWorkflow.com