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STATE OF CALIFORNIA –

DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

NOTICE OF TRANSACTION PURSUANT TO CORPORATIONS CODE

SECTION 25102(f)

DFPI-260.102.14(c) Packet (Rev. 09-21)

As of July 22, 2005, the Limited Offering Exemption Notice pursuant to Corporations Code

Section 25102(f) is required to be filed electronically unless a hardship exception is

claimed. Please see the enclosed instructions in Section 260.102.14(f) for the information

on claiming an exception to filing electronically. To file electronically, see

the Department of Financial Protection and Innovation's Web site at http://

www.dfpi.ca.gov/.

This packet provides information and forms to assist in the preparation and filing of a Notice of

Transaction Pursuant to Corporations Code Section 25102(f). Applicable statutes have

been excerpted from the California Corporations Code and Title 10, Chapter 3, California

Code of Regulations to assist in this process. Please review all material prior to completing

the Notice. The current Notice and Consent to Service of Process forms are provided in this

packet. DO NOT RETURN THE ENTIRE PACKET; INFORMATION MATERIALS SHOULD

BE RETAINED FOR YOUR FUTURE REFERENCE

Please note that the Department does not supply

receipt

for submitted filing fees nor any other form of

acknowledgement to confirm receipt of your filing. Your

canceled check o r S e l f S e r v i c e P o r t a l p a y m e n t

e - r e c e i p t will serve as your receipt for payment of fees.

If you wish an endorsed copy of the paper filed Notice to be

returned to you, you must include an additional copy of the

form at the time of filing, a letter requesting return of an

endorsed copy and a self-addressed stamped (postage)

envelope.

If you are claiming an exception to filing electronically, your Notice may be filed by

US mail or in person at any of our

office

locations. If you have questions or

need assistance, you may contact us toll-free (866) 275-2677 or (916) 576-4941.

General inquiries may be sent mailto:Ask.DFPI@dfpi.ca.gov.

320 West 4

Street, Suite 700

Los Angeles, CA 90013-2344

(213) 576-7500

DFPI MAIN OFFICE

2101 Arena Blvd

Sacramento, CA 95834

(916) 576-4941

(866) 275-2677

1455 Frazee Road, Suite 315

San Diego, CA 92108-4304

(619) 610-2093

One Sansome Street, Suite 600

San Francisco, CA 94104-4428

(415) 972-8565

STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

NOTICE OF TRANSACTION PURSUANT TO CORPORATIONS

CODE SECTION 25102(f)

DFPI-260.102.14(c) Packet (Rev. 09-21) Page 2 of 14

CALIFORNIA CORPORATIONS CODE

Section 25102. Transactions exempt from the provisions of Section 25110.

(f) Any offer or sale of any security in a transaction (other than an offer or sale to a

pension or profit-sharing trust of the issuer) that meets each of the following criteria:

(1) Sales of the security are not made to more than 35 persons, including persons

not in this state.

(2) All purchasers either have a preexisting personal or business relationship with the

offeror or any of its partners, officers, directors or controlling persons, or managers (as

appointed or elected by the members) if the offeror is a limited liability company, or by reason

of their business or financial experience or the business or financial experience of their

professional advisers who are unaffiliated with and who are not compensated by the issuer or

any affiliate or selling agent of the issuer, directly or indirectly, could be reasonably assumed

to have the capacity to protect their own interests in connection with the transaction.

(3) Each purchaser represents that the purchaser is purchasing for the purchaser's own

account (or a trust account if the purchaser is a trustee) and not with a view to or for sale in

connection with any distribution of the security.

(4) The offer and sale of the security is not accomplished by the publication of any

advertisement. The number of purchasers referred to above is exclusive of any described in

subdivision (i), any officer, director, or affiliate of the issuer, or manager (as appointed or

elected by the members) if the issuer is a limited liability company, and any other purchaser

who the commissioner designates by rule. For purposes of this section, a husband and wife

(together with any custodian or trustee acting for the account of their minor children) are

counted as one person and a partnership, corporation, or other organization that was not

specifically formed for the purpose of purchasing the security offered in reliance upon this

exemption, is counted as one person. The commissioner may by rule require the issuer to file

a notice of transactions under this subdivision.

The failure to file the notice or the failure to file the notice within the time specified by

the rule of the commissioner shall not affect the availability of this exemption. An issuer who

fails to file the notice as provided by rule of the commissioner shall, within 15 business days

after discovery of the failure to file the notice or after demand by the commissioner, whichever

occurs first, file the notice and pay to the commissioner a fee equal to the fee payable had the

transaction been qualified under Section 25110.

Section 25608. Fees, charge and collection; disposition

and the fee for filing a notice pursuant to paragraph (4) of subdivision (f) of Section 25102, in

addition to the fee prescribed in those paragraphs, if applicable, shall be determined based on

the value of the securities proposed to be sold in the transaction for which the notice is filed

and in accordance with subdivision (g), and shall be as follows:

STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

NOTICE OF TRANSACTION PURSUANT TO CORPORATIONS CODE SECTION 25102(f)

DFPI-260.102.14(c) Packet (Rev. 09-21) Page 3 of 14

Value of Securities Filing Fee

Proposed to be Sold

$25,000 or less $ 25

$25,001 to $100,000 $ 35

$100,001 to $500,000 $ 50

$500,001 to $1,000,000 $150

Over $1,000,000 $300

TITLE 10, CHAPTER 3, CALIFORNIA CODE OF REGULATIONS

260.103. Exemption from Qualification of Recapitalizations and Reorganizations.

(a) Pursuant to the authority contained in Section 25105 of the Code, the following

transactions are exempted from the provisions of Section 25120 of the Code as not being

comprehended within the purposes of the Corporate Securities Law of 1968 and the

qualification of which is not necessary or appropriate in the public interest or for the protection

of investors:

(1) Any change in the rights, preferences, privileges, or restrictions of or on

outstanding securities, and any exchange of securities by the issuer with its existing security

holders exclusively, if the transaction, had it involved the issuance of a new security

containing the changed rights, preferences, privileges, or restrictions, or a new issuance of

the exchange security, would have been exempt from the provisions of Section 25110 of the

Code by any of the subdivisions of Section 25102 of the Code or Section 260.105.14 of these

rules; and

(2) Any exchange of securities in connection with any merger or consolidation or sale

of corporate assets in consideration wholly or in part of the issuance of securities under, or

pursuant to, a plan of reorganization or arrangement which, pursuant to the provisions of the

Bankruptcy Code, has been confirmed or is subject to confirmation by the decree or order of

a court of competent jurisdiction.

(b) A transaction conducted under this rule by reason of the provisions of subdivisions

(f), (h) or (n) of Section 25102 requires the issuer to file the notice prescribed thereunder

(see Rules 260.102.8, 260.102.14, and 260.102.16).

260.102.12. Limited Offering Exemption-Interpretations.

(a) The provisions of this section apply to the provisions of Section 25102(f) of the

Code. (b) Integration. The term "transaction" does not include

(1) any offer or sale of a security made more than 6 months before the start of an offering under

the exemption or made more than six months after completion of an offering under the exemption,

so long as during those six month periods there are no offers or sales of securities

STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

NOTICE OF TRANSACTION PURSUANT TO CORPORATIONS CODE SECTION 25102(f)

DFPI-260.102.14(c) Packet (Rev. 09-21) Page 4 of 14

or for the issuer that are of the same or a similar class as those offered or sold

pursuant to the exemption, other than those offers or sales of securities under any

purchase, savings, option, bonus, appreciation, profit-sharing, thrift, incentive, pension or

similar plan solely for employees, directors, trustees or officers of

the issuer or a subsidiary

of the issuer (note: Section 25102(f) is not available for an offer or sale of a security to a

pension or profit-sharing trust of the issuer),

(2) any offer or sale of a security pursuant to a qualification under Section 25110 or

25120 which became effective after the filing of the notice of the transaction pursuant to

Rule 260.102.14, or in which the application for qualification discloses the transaction under

the exemption, whether past, current or proposed. This subsection does not create any

presumption that offers and sales not excluded from the transaction by its provisions are to

be integrated for the purposes of the exemption and that determination shall be made without

reference to this subsection.

ownership of the security, whether individually or in joint ownership, in the transaction under

the exemption. Each person who takes in joint ownership with another is to be counted as

one except as otherwise provided in Section 25102(f).

(d) Relationship.

(1) The term "preexisting personal or business relationship" includes any relationship

consisting of personal or business contacts of a nature and duration such as would enable a

reasonably prudent purchaser to be aware of the character, business acumen and general

business and financial circumstances of the person with whom such relationship exists. A

relationship of employer-employee, or as a security holder of the issuer, or as a customer of

a broker-dealer, investment adviser or other person, does not necessarily involve contacts

of a nature which are sufficient to establish a "preexisting personal or business relationship"

within the meaning of Section 25102(f). This subsection does not create any presumption

that relationships not falling within its terms are not within the statutory language, and the

determination of whether or not such a relationship is within the statutory language shall be

made without reference to this subsection.

(2) The phrase "all purchasers" used in Section 25102(f)(2) of the Code does not

include purchasers excluded from the count of purchasers by virtue of Section 25102(f)(4)

or Rule 260.102.13.

(e) Partners. The term "partners" in Section 25102(f)(2) means general partners.

(f) Controlling Person. The term "controlling person of the offeror" includes but is

not limited to a person who, in connection with transactions within one year of the formation of

the issuer, is a "promoter" of the issuer. "Promoter" means a person who, acting alone or in

conjunction with one or more other persons, takes the initiative in founding and organizing

the business or enterprise of an issuer.

(g) Professional Advisor. The term "professional advisor" means a person who,

as a regular part of such person's business, is customarily relied upon by others for

investment recommendations or decisions, and who is customarily compensated for such

services, either specifically or by way of compensation for related professional services, and

attorneys and certified public accountants.

STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

NOTICE OF TRANSACTION PURSUANT TO CORPORATIONS CODE SECTION 25102(f)

DFPI-260.102.14(c) Packet (Rev. 09-21) Page 5 of 14

(1) The foregoing includes but is not limited to persons licensed or registered as

broker- dealers, agents, investment advisers, banks and savings and loan associations. The

foregoing also includes licensed real estate brokers with respect to those securities referred to

in Section 25206 of the Code.

(2) A person is not the professional advisor of a purchaser unless designated as such

by the purchaser.

(h) Unaffiliated. The relationships which will render a person not "unaffiliated" include

(1) a present or intended relationship of employment, either as an employee,

employer, independent contractor or principal,

(2) any relationship within the definition of the term "affiliate" or as an officer or

director of an affiliate and

(3) the beneficial ownership by the professional advisor of securities of the issuer

or its affiliates or selling agent, except that the ownership of 1% or less of such

securities shall not render a professional advisor not unaffiliated.

(i) Affiliate. "Affiliate" of the issuer means a person controlling, controlled by or

under common control with, the issuer. A person controls another person within the

meaning of this subsection through the possession, direct or indirect, of the power to direct

or cause the direction of the management, policies or actions of such other person.

(j) Publication of Advertising. Section 25102(f)(4) of the Code is to be interpreted

so as to facilitate the circulation of disclosure materials to offerees and purchasers, so long as

such materials are not disseminated to the public (see Sections 25002 and 25014 of the

Code). Private placement memoranda, offering circulars and similar disclosure documents

are not "disseminated to the public" for the purposes of Section 25102(f) of the Code if the

issuer limits such circulation

(1) to persons reasonably believed to be interested in purchasing the securities or

(2) to persons whom the issuer believes may meet the qualifications required of

purchasers pursuant to such section and the rules thereunder, provided with respect to

clause (1) and clause (2) that neither the issuer nor any person acting on its behalf shall offer

or sell the securities by any form of general solicitation or general advertising, including, but

not limited to, the following:

(A) Any advertisement, article, notice or other communication published in

any newspaper, magazine, or similar media or broadcast over television or radio; and

(B) Any seminar or meeting whose attendees have been invited by any general

solicitation or general advertising. The preceding sentence does not create any presumption

that a dissemination of materials otherwise than as described therein is a "publication of

advertising," and the determination of that question shall be made without reference to that

sentence.

STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

NOTICE OF TRANSACTION PURSUANT TO CORPORATIONS CODE SECTION 25102(f)

DFPI-260.102.14(c) Packet (Rev. 09-21) Page 6 of 14

(k) Institutional Investors. The reference in Section 25102(f) of the Code to

purchasers described in Section 25102(i) includes those persons designated in Rule

260.102.10.

(l) For purposes of Section 25102(f), when a person is both an "affiliate of the issuer"

or a purchaser excluded by Rule 260.102.13 and a partnership, corporation or other

organization which was specifically formed for the purpose of purchasing the security

offered in reliance upon the exemption, each beneficial holder of its securities shall be

counted or excluded from the count in accordance with the provisions of Section 25102(f).

260.102.13 Limited Offering Exemption-Excluded Purchasers.

For the purposes of Section 25102(f) of the Code, the following purchasers are

excluded from the count of purchasers for purposes of Subparagraph (1) of that subdivision,

except as provided in Subsection (l) of Rule 260.102.12:

(a) The trustee of an issuer which is a trust and the general partner of an issuer which

is a partnership, who exercise managerial functions with respect to such entities, and any

officer, director or general partner of a general partner of an issuer which is a partnership.

(b) Any person who occupies a position with the issuer, or with a general partner

of an issuer which is a partnership, with duties and authority substantially similar to

those of an executive officer of a corporation.

principal residence as the purchaser;

(2) any trust or estate in which a purchaser and any of the persons related to such

purchaser as specified in Clause (1) or Clause (3) collectively have more than 50% of the

beneficial interest (excluding contingent interests); and

(3) any corporation or other organization of which a purchaser and any of the persons

related to such purchaser as specified in Clause (1) or Clause (2) collectively are beneficial

owners of more than 50% of the equity securities (excluding director's qualifying shares) or

equity interests. "Relative" means a person related by blood, marriage or adoption.

(d) Any individual who is a "promoter" of the issuer, as defined in Subsection (f)

Section 260.102.12.

(e) Any person who purchases $150,000 or more of the securities offered in

the transaction, provided each such purchaser meets either one of the following, or who the

issuer reasonably believes comes within either of the following:

(1) Such person, or such person's professional advisor, has the capacity to protect

such person's own interests in connection with the transaction, as provided in Section

25102(f)(2).

STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

NOTICE OF TRANSACTION PURSUANT TO CORPORATIONS CODE SECTION 25102(f)

DFPI-260.102.14(c) Packet (Rev. 09-21) Page 7 of 14

(2) T

he investment (in

cluding mandatory assessments) does not exceed 10% of such

person's net worth or joint net worth with that person's spouse.

(f) A small business investment company licensed by the U.S. Small Business

Administration under Section 301(c) or (d) of the Small Business Investment Company

Act of 1958, and a business development company as defined in Section 2(a)(48) of the

Investment Company Act of 1940, and a private business development company as

defined in Section 202(a)(22) of the Investment Advisors Act of 1940.

(g) A person who comes within one of the categories of an "accredited investor" in

Rule 501(a) of Regulation D adopted by the Securities and Exchange Commission under the

Securities Act of 1933 (17 CFR Sec. 230.501(a)).

(h) Any entity in which all of the equity owners are persons specified in Section

25102(i) of the Code; Rule 260.102.10; or subsections (a), (b), (c), (d), (f) and (g) of this rule;

or who are "officers, directors or affiliates of the issuer" as that term is used in Section

25102(f) of the Code.

260.102.14 Limited Offering Exemption Notice of Transaction.

(a) An issuer who conducts a transaction under section 25102(f) of the Code shall file

a notice with the Commissioner as follows:

(1) If in connection with the transaction the issuer is filing a notice with the Securities

and Exchange Commission pursuant to section 4(6) of the Securities Act of 1933 or

Regulation D (Rule 230.503), the notice may be a copy of the form first filed pursuant to

those provisions. The fee required by section 25608(c) of the Code must accompany the

filing. Each issuer (other than a California corporation) must also file a consent to service of

process (Form 260.165), unless it already has a consent to service on file with the

Commissioner. The filing should be accompanied with a cover letter indicating that the

filing is pursuant to section 25102(f), and if a consent to service is not included, a

statement that the issuer already has a consent to service on file with the Commissioner.

(2) Unless a notice is filed pursuant to paragraph (1), the notice shall be filed

electronically through the Internet process made avail

able by the Department on

www.dfpi.ca.gov. If the issuer claims the exception under subsection (f), the notice shall be in

the form and contain the information specified by subsection (c) and in accordance with the

instructions in subsection (d).

(b) A notice required by this section shall be filed with the Commissioner no later than

15 calendar days after the first sale of a security in the transaction in this state. No notice is

required if none of the securities offered are purchased in this state.

ubsection

(a)(2) that are subject to the hardship exception to electronic filing under subsection (f):

(d) Instructions. The following instructions apply to the form specified in subsection (c):

STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

NOTICE OF TRANSACTION PURSUANT TO CORPORATIONS CODE

SECTION 25102(f)

DFPI-260.102.14(c) Packet (Rev. 09-21) Page 8 of 14

COMMISSIONER OF FINANCIAL PROTECTION AND

INNOVATION OF THE STATE OF CALIFORNIA NOTICE OF

TRANSACTION PURSUANT TO CORPORATIONS CODE

SECTION 25102(f) INSTRUCTIONS

1. This N

otice is to provide information on transactions conducted under the section

25102(f) exemption from the qualification requirements of Section 25110 of the Corporate

Securities Law of 1968 and under the Rule 260.103 exemption from the qualification

requirements of Section 25120 of that Law. The form is not designed to indicate whether or

not the transaction complies with the requirements of those exemptions but only to provide

notice to the Commissioner that the exemption is being relied on.

2. When to File Notice. The Notice must be filed with, or mailed to, the Commissioner

within 15 calendar days after the first sale of a security in the transaction in this state.

However, for purposes of determining the filing fee, a filing received before demand by the

Commissioner shall be deemed filed as provided by rule of the Commissioner, provided that

the obligation to file within 15 calendar days after the first sale of a security in the transaction

in this state has not been intentionally disregarded. (See Corporations Code section

25102(f)(4).) The first sale in this state occurs when the issuer has obtained a contractual

commitment in this state to purchase one or more of the securities the issuer intends to sell

in connection with the transaction. No notice is required if none of the securities offered are

purchased in this state. No subsequent notices are required for sales in connection with the

same transaction. The information required by the form is to relate to the entire transaction,

not just the first sale or sales in this state.

3. The Heading and Filing Fee. The Notice may be filed in person or by mail at any

office of the Department. If the issuer has previously qualified securities with the

Department, insert the file number of the qualification in the upper right hand corner of the

form in the space provided. Circle the appropriate fee for filing this Notice. The fee is based

on the value of all securities sold or intended to be sold in the entire transaction as follows

(see Item 6 for valuing securities):

Value of Securities Filing Fee

$25,000 or less $25

$25,001 - $100,000 $35

$100,001 - $500,000 $50

$500,001 - $1,000,000 $150

Over $1,000,000 $300

Filing Fee: Each notice, whether under 25102(f) or Rule 260.103, must be

accompanied by the filing fee required by Section 25608(c) of the Code as described

above.

Item A. Check appropriate box for exemption being relied on.

Item 1. Give the issuer's legal name.

Item 2. Give the street address, and the mailing address if different, of the issuer's

principal place of business.

STATE OF CALIFORNIA –DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

NOTICE OF TRANSACTION PURSUANT TO CORPORATIONS CODE SECTION

25102(f) DFPI-260.102.14(c) Packet (Rev. 09-21) Page 9 of 14

Item 3. Give the telephone number of issuer's principal place of business.

Item 4. Give the name of the state or other jurisdiction under whose laws the issuer is

incorporated or organized. If the issuer is not incorporated or organized under the laws of any

jurisdiction, provide the name of the jurisdiction where issuer is domiciled and include

parenthetical "(domicile)."

Item 5. Set forth the name or title of each class or type of security to be sold in the

transaction.

Item 6. See Corp. Code sec. 25608(g). Generally, the value of the securities shall be

the price at which the issuer proposes to sell the securities, as alleged in the notice, or the

actual value of the consideration (if other than money) to be received in exchange for the

securities. See sec. 25608(g) for valuing voting trust certificates, warrants, rights, and share

dividends. Complete the amounts in (a)(i), (ii) and (iii) in both the California and the Total

Offering columns.

Item 7. If the transaction was registered under the Securities Act of 1933, insert

"Registration Statement". If conducted pursuant to an exemption from registration under that

Act which requires a filing with the Securities and Exchange Commission, indicate the number

of the rule pursuant to which such filing was made. If no such filing was made, insert "none."

Item 8. If the notice is not filed electronically through the Internet process made

available by the Department at www.dfpi.ca.gov, then complete the hardship exception by

checking the applicable box and describing the reason(s) and description(s) for the hardship

exception, as specified.

Item 9. Consent to Service of Process. Corporations Code section 25165 requires

each issuer, other than a California corporation, to file a consent to service of process with the

notice filed pursuant to section 25102(f) unless it already has a consent to service on file with

the Commissioner. If the issuer already has a consent to service of process on file with the

Commissioner, check the box. If no consent to service of process is on file with the

Commissioner, attach the consent to this notice. Use Form 260.165 (see Rule 260.165, Title

10, California Code of Regulations).

Item 10. Date, Signature and Contact. The notice shall be signed and dated by an

authorized officer, director, general partner or trustee of the issuer (or a person occupying a

position with the issuer of equivalent responsibility) or by the authorized attorney of the issuer.

If the person the Department is to contact in the event of questions concerning the transaction

or the notice is different than the signer, insert the contact person's name, telephone number

and correspondence address in the spaces provided. Otherwise, provide this information with

respect to the signer.

(e) Electronic Filing. An issuer shall file a notice electronically through the Internet

process made available by the Department, except as provided in subdivision (f).

STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

NOTICE OF TRANSACTION PURSUANT TO CORPORATIONS CODE SECTION 25102(f)

DFPI-260.102.14(c) Packet (Rev. 09-21) Page 10 of 14

The following shall apply to any person filing electronically:

(1) In addition to the information requested in subsection (c), an issuer that files a notice

electronically shall provide a Federal Employer Identification Number for the issuer

and, if applicable, a Federal Employer Identification Number for a representative

filing on behalf of the issuer.

(2) The instructions and explanations in subsection (d) are applicable to the same

information requested through the electronic filing.

(3) An issuer (other than a California Corporation) filing a notice electronically shall file

electronically an irrevocable consent appointing the Commissioner to be the issuer’s

attorney to receive service of process under Section 25165 of the Code.

(4) An issuer filing the notice electronically shall print a copy of the notice and manually

sign and date the notice pursuant to the instructions in Item 8 of subsection (d).

The notice shall be executed before or at the time the electronic filing is made and

shall be retained by the issuer for a period of five years from the date of filing.

(5) Upon request, the issuer shall provide to the Commissioner the manually

signed notice.

(6) An issuer filing the notice electronically shall pay the filing fee electronically by

credit card. A notice is not deemed filed until the filing fee is submitted.

(f) Hardship exception for electronic filing. An issuer may file the paper notice in

person or by mail only if:

(1) computer equipment including hardware and software is unavailable to the

issuer without unreasonable burden or expense, and the issuer describes in the

notice both of the following: (A) the reason(s) that the computer equipment

including hardware and software is unavailable without unreasonable burden or

expense; and (B) the description(s) of the unreasonable burden or expense to the

issuer to make the electronic filing; or

(2) the issuer cannot obtain and provide information requested on the Department's

electronic notice or through the Internet filing process, and the issuer describes in

the notice both of the following: (A) the reason(s) that the issuer cannot obtain and

provide the requested information on the electronic notice or through the Internet

filing process without unreasonable burden or expense; and (B) the description(s)

of the unreasonable burden or expense to the issuer to make the electronic filing.

STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

NOTICE OF TRANSACTION PURSUANT TO CORPORATIONS CODE SECTION 25102(f)

DFPI–260.102.14(c) Packet (Rev. 09-21) Page 11 of 14

(Department of Financial Protection and

Innovation Use Only)

Fee paid $________________

DEPARTMENT OF FINANCIAL PROTECTION AND

INNOVATION FILE NO., if any:

______________________________________________

Fee: $25.00 $35.00 $50.00 $150.00 $300.00

(Check the appropriate amount of fee. See Corporations Code Section 25608(c))

A. Check one: Transaction under Section 25102(f) Rule 260.103. (Fee: $25.00)

ELECTRONIC FILING REQUIREMENT AND HARDSHIP EXCEPTION:

This notice must be filed electronically through the Internet process made available by the

Department of Financial Protection and Innovation at www.dfpi.ca.gov, unless the issuer

claims the hardship exception as described in Number 8 below.

1. Name of Issuer:

___________________________________________________________________________________

2. Address of Issuer:

___________________________________________________________________________________

Street City State Zip

Mailing Address:

___________________________________________________________________________________

Street City State Zip

3. Area Code and Telephone Number:

_______________________________________________________

4. Issuer's state (or other jurisdiction) of incorporation or organization:

___________________________________________________________________________________

5. Title of class or classes of securities sold in transaction:

6. The value of the securities sold or proposed to be sold in the transaction, determined in accordance with

Corporations Code Sec. 25608(g) in connection with the fee required upon filing this notice, is (fee

based on amount shown in line (iii) under "Total Offering"):

California Total Offering

(a)(i) in money $_____________ $_____________

(ii) in consideration other than money $_____________ $_____________

(iii) total of (i) and (ii) $_____________ $_____________

(b) Change in rights, preferences, privileges or restrictions of or on outstanding securities

($25.00 fee.) (See Rule 260.103.)

0.00

STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

NOTICE OF TRANSACTION PURSUANT TO CORPORATIONS

CODE SECTION 25102(f)

DFPI–260.120.14(c) Packet (Rev. 09-21) Page 12 of 14

7. Type of filing under Securities Act of 1933, if applicable: _____________________________________

___________________________________________________________________________________

8. Hardship Exception for electronic filing. An issuer may file this paper notice in person or by mail only

if either of the following exceptions apply. The issuer shall check applicable box and include the

reason(s) and description(s) for the hardship exception in the space provided.

Computer equipment including hardware and software is unavailable to the issuer without

unreasonable burden or expense. If this is the case, describe below both of the following; the

reason(s) that the computer equipment including hardware and software is unavailable without

unreasonable burden or expense, and the description(s) of the unreasonable burden or expense.

The issuer cannot obtain and provide information (including credit card or other identifying

information) requested on the Department's electronic notice or through the Internet filing process.

If this is the case, describe below both of the following: the reason(s) that the issuer cannot obtain

and provide the requested information on the electronic notice or through the Internet filing process

without unreasonable burden or expense, and the description(s) of the unreasonable burden or

expense to the issuer to make the electronic filing.

After checking the applicable hardship exception above, the issuer shall describe below the reason(s)

and description(s) for that hardship exception. (If additional space is needed, attach a separate sheet to

this notice.)

9. Check if issuer already has a consent to service of process on file with the Commissioner.

(Instruction: Each issuer (other than a California Corporation) filing a notice under Section 25102(f)

must file a consent to service of process (Form 260.165), unless it already has a consent to service

on file with the Commissioner. If no consent to service of process is on file with the Commissioner,

attach the consent to this notice.)

10. ___________________________________________________

Authorized Signature on behalf of issuer

___________________________________________________

Print name and title of signatory

___________________________________________________

Date

Name, Address and Phone number of contact person:

____________________________________________________________________________________

STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

NOTICE OF TRANSACTION

PURSUANT TO CORPORATIONS CODE SECTION 25102(f)

DFPI–260.120.14(c) Packet (Rev. 09-21) Page 13 of 14

TO THE COMMISSIONER OF FINANCIAL

PROTECTION AND INNOVATION OF THE

STATE OF CALIFORNIA

KNOW ALL MEN BY THESE PRESENTS:

That the undersigned,

(a corporation,

partnership or limited liability company organized under the laws of the State of ),

(an individual),

(other entity),

hereby irrevocably appoints the Commissioner of Financial Protection and Innovation of the State of

California, or the Commissioner's successor in office, to be the undersigned's attorney to receive service

of any lawful process in any noncriminal suit, action or proceeding against the undersigned, or the

undersigned's successor, executor, or administrator which arises under the Corporate Securities Law of

1968 or any rule or order thereunder after this consent has been filed, with the same force and validity as

if served personally on the undersigned.

For the purpose of compliance with the Corporate Securities Law of 1968 of the State of

California, notice of the service and a copy of the process should be sent by registered or certified mail to

the undersigned at the following address:

(Name and Address)

Dated: , .

[Insert name of corporation,

partnership, limited liability company or

other entity]

Title

[Insert name of individual]

STATE OF CALIFORNIA – DEPARTMENT OF FINANCIAL PROTECTION AND INNOVATION

NOTICE OF TRANSACTION PURSUANT TO CORPORATIONS CODE

SECTION 25102(f)

DFPI–260.102.14(c) Packet (Rev. 09-21) Page 14 of 14

State of California___________________)

County of _________________________)

On __________________________ before me, ______________________________________,

(Name of Notary)

personally appeared _________________________________________________________________

(Here, insert Name and Title of the Officer)

who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are

subscribed to the within instrument and acknowledged to me that he/she/they executed the same in

his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the

person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing

paragraph is true and correct.

WITNESS my hand and official seal.

Signature ____________________________ (Seal)

Any certificate of acknowledgement taken in another place shall be sufficient in the State of

California if it is taken in accordance with the laws of the place where the acknowledgment is made.

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Fillable NOTICE OF TRANSACTION PURSUANT TO CORPORATIONS CODE SECTION (California)

Fill Online, Printable, Fillable, Blank NOTICE OF TRANSACTION PURSUANT TO CORPORATIONS CODE SECTION (California) Form

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