Fillable Form CF Renewal Filing ($100 fee): (Mark one) (Illinois Secretary of State)

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Form CF Renewal Filing ($100 fee): (Mark one) (Illinois Secretary of State)

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(Mark one)
Form CF Initial Filing ($100 fee)
Amendment to Form CF ($100 fee)
Form CF Renewal Filing ($100 fee)
1. Issuer and Offering Information (the Issuer is the entity issuing securities):
_______________________________________ _______________________________________________
Name Street Address
_______________________________________ _______________________________________________
Telephone Number City, State, ZIP
_______________________________________ _______________________________________________
Website Address Email Address
_______________________________________
FEIN Number
2. Contact to whom Communications regarding this Notice should be directed:
_______________________________________ _______________________________________________
Name Street Address
_______________________________________ _______________________________________________
Telephone Number City, State, ZIP
_______________________________________
Email Address
3. Name and website address of the registered Internet Portal through which the offering will be
conducted:
_______________________________________________________________________________________
4. Amount of compensation to be paid to the registered Internet Portal (dollar or percentage of offering
amount; estimate if exact amount is not available at time of filing): $____________________________
5.
Name
and address of the bank or other depository institution where investors’ funds are to be
deposited in escrow (attach copy of escrow agreement): _______________________________________
Form CF
Crowdfunding Issuer Notice
Illinois Secretary of State
Securities Department
69 W. Washington St., Ste. 1220
Chicago, IL 60602 • 312-793-3384
Crowdfunding@ilsos.net
Printed!by!authority!of!the!State!of!Illinois.!April!2016!—!1!—!SEC!350!
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Form CF
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6. Issuer’s predecessors, owners, officers, directors and control persons. In the chart that follows, list
the names of the following persons:
a.
Any predecessor of the Issuer; and
b.
Each officer, director, or other person having the power, directly or indirectly, to direct the
management or policies of the Issuer, whether by contract or otherwise; and
c.
Each person that owns, beneficially owns, has the right to vote, or has the power to sell or direct
the sale of 20% or more of a class of the Issuer’s voting securities. For purposes of this
provision, a person beneficially owns any securities: (i) owned by his/her child, stepchild,
grandchild, parent, stepparent, grandparent, spouse, sibling, mother-in-law, father-in-law, son-in-
law, daughter-in-law, brother-in-law, or sister-in-law, sharing the same residence; or (ii) that
he/she has the right to acquire, within 60 days, through the exercise of any option, warrant, or
right to purchase the security.
Complete the Title/Status column by entering predecessor or board/management titles; status as
partner, trustee, sole proprietor, elected manager, shareholder, or member; and for shareholders or
members, the class of securities owned (if more than one is issued).
Enter an ownership code if applicable. Ownership codes are:
A - Less than 20% B - 20% or more but less than 50%
C - 50% or more but less than 75% D - 75% or more
Full Name Title/Status Ownership Code
Form CF
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7. Attach copy of Offering Statement
8. By filing this Crowdfunding Issuer Notice, the Issuer of these securities hereby represents that
the
issuer, the issuer’s predecessors, any affiliated issuer, the issuer's directors, officers, control
persons:
1.
has not within the last five years, filed a registration statement which is the subject of a currently
effective registration stop order entered by any state securities administrator or the United States
Securities and Exchange Commission; or
2.
has not within the last five years, been convicted of any criminal offense in connection with the
offer, purchase, or sale of any security, or involving fraud or deceit; or
3.
is not currently subject to any state or federal administrative enforcement order or judgment, entered
within the last five years, finding fraud or deceit in connection with the purchase or sale of any
security; or
4.
is not currently subject to any order, judgment, or decree of any court of competent jurisdiction,
entered within the last five years, temporarily, preliminarily, or permanently restraining or enjoining
such party from engaging in or continuing to engage in any conduct or practice involving fraud or
deceit in connection with the purchase or sale of any security.
9. CONSENT TO SERVICE OF PROCESS. Attach completed Form U-2 Uniform Consent to Service
of Process.
10. The undersigned represents that the Issuer is familiar with the conditions that must be satisfied to
be entitled
to the Intrastate Crowdfunding Exemption 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
Notice 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.
The undersigned affirms that to the best of his or her knowledge, information, and belief the statements
made
on this form are true.
_________________________ _______________________________________________
Date Name of Representative of Issuer (type or print)
____________________________________________________
Signature of Representative of Issuer
____________________________________________________
Title
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Form CF Renewal Filing ($100 fee): (Mark one) (Illinois Secretary of State)

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Completed 28 August 2020

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