NOTICE OF CANCELLATION OF INVESTMENT

An investor who wants to cancel his or her investment in a crowdfunding offering under RCW 21.20.880 may do so by completing this form and submitting it to the issuer.

As provided in WAC 460-99C-120, in an offering conducted under RCW 21.20.880, an investor may cancel an investment commitment for any reason until such time as the target minimum offering amount has been raised. This form serves to provide notice to the Company that the investor listed below is exercising the right to cancel his or her investment commitment with the Company.

The Company must immediately cancel the investment commitment of the investor and direct the escrow agent to return any funds committed by the investor listed below.

Name of Investor:

Date of Investment:

Investment Amount:

Investor Contact Information:

Last Name	First Name	Title
Firm Name	Street Address Line 1	Street Address Line 2
City	State/Province/Country	ZIP/Postal Code
Phone	Fax	E-mail

Signature	Name of Signer (Print)
Date