STATE OF WASHINGTON

Department of Financial Institutions

Securities Division

PO Box 41200

Olympia, WA 98504-1200

360-902-8760

FINAL REPORT OF SALES

FILE NUMBER:

(Exact name of Company as set forth in the organizational documents).

(Insert the names of any DBAs, if applicable)

Click to select date.

Click to select date.

The offering began on and ended on:

$

Securities sold – Number of shares/units: Dollar amount:

Total number of purchasers:

Chief Executive Officer/President/Managing Member	Name of Signer (Print)
Title	Date