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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
Date Offering Began: _____________________________
Date Offering Ended: _____________________________
Number of Shares (units) sold: _____________________
Total Dollar Amount sold: _________________________
Total Number of Purchasers: _______________________
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
Illinois Secretary of State
Securities Department
69 W. Washington St., Ste. 1220
Chicago, IL 60602 • 312-793-3384
Crowdfunding@ilsos.net
