Application To Register Securities {6(A)(4)}

Form 6(A)(4) File Number Registration by a Corporation of a Proposed Sale of Additional Securities to Existing Security Holders Pursuant to R.C. Section 1707.06(A)(4). Registrant Must Not Complete DIVISION RECORD ONLY Date Checke d By Notation Fee ($50.00) Received Prior registrations checked Examined as to form Amendment requested Accepted for filing Acknowledgment sent Registration withdrawn Registration suspended Registration ref used Examination requested This Registration ( Registrant Must Not Complete.) (Price) dkdkdkdkdkdkd (Section) (File) (Date) (Amount) (Description) Note: Use this form if sub - items (a), (b) and (c) of item 11 can be answered in the affirmative. Check each of these sub - items before starting to complete this form. If the space provided on this form is inadequate for f ull response, attach an exhibit numbered to correspond to the number of the question thereby answered. Integration: The issuer should be aware that all sales of securities before or after this filing may be subject to integration with this offering by th e Division. Factors considered particularly relevant to integration include: 1) Are the offerings part of a single plan of financing? 2) Do the offerings involve issuance of the same class of security? 3) Are the offerings made at or about the same time? 4) Is the same type of consideration to be received? 5) Are the offerings made for the same general purpose? Division of Securities 77 South High Street 22 nd Floor Columbus, Ohio 43215 COM 4653 4/11 / 19 An Equal Opportunit y Employer and Service Provider 614 - 644 - 7381 Fax : 614 - 728 - 2846 Investor Protection Hotline: 877 - 683 - 7841 TTY/TDD : 800 - 750 - 0750 com.ohio.gov American LegalNet, Inc. www.FormsWorkFlow.com Ohio Department of Commerce FORM 6(A)(4) COMPLETE AL L ITEMS 1. 2. (Street and Number) (City, State, Zip) (Phone) 3. Statutory Agent: (Name) (Street and Number) (City, State, Zip) (Phone) 4. (Month, Day and Year) (City, State, Zip) (State) 5. State specifically the actual business in which issuer is engaged or will engage: 6. Securities authorized and securities sold: a. Shares now authorized by Articles of Incorporation, including amendments, if any: I Common II Preferred III Other Classes Description No. of Shares No. of Shares No. of Shares Par Valu e Par Value Par Value Voting Dividend Rate Dividend Rate Cumulative Cumulative Voting Voting b. Total number of shares sold, issued or subscribed to date. I Common II Preferred III Other Classes Description No. of Shares No. of Shares No. of Shares c. Attach an exact copy of any language in the Articles of Incorporation, including amendments, and in the Code of Regulations or By - Laws relating to: (1) voting rights; (2) divid end rights; (3) liquidation rights; (4) pre - emptive rights; (5) subscription rights (6) conversion rights; and (7) redemption provisions of the - Laws, a statement should be made that shareholders have only such rights as are provided by statute. American LegalNet, Inc. www.FormsWorkFlow.com Ohio Department of Commerce FORM 6(A)(4) d. debentures, trust certificates, etc. State: (1) amount outstanding; (2) date of issue; (3) date of maturity; (4) interest rate; (5) nature of security therefore; and (6) conversion rights. (If none, so state.) 7. State number, class, price and amount of all shares, preferred or common, to be the subject matter of the transaction described by this registration for sale in Ohio. (If none, so state). (No. of Shares) (Description of Shares) (Exact Sale Price of Share) (Total Sale Price of all Shares) (No. of Shares) (Description of Shares) (Exact Sale Price of Share) (Total Sale Price of all Shares) 8. sold outside of Ohio. (If none , so state.) (No. of Shares) (Description of Shares) (Exact Sale Price of Share) (Total Sale Price of all Shares) (No. of Shares) (Description of Shares) (Exact Sale Price of Share) (Total Sale Price of all Shares) 9. promissory notes, bonds or debentures: a. To be the subject matter of the transaction described by this registration for sale in Ohio. (If none, so state.) b. To be sold outside Ohio. (If none, so state.) 10. a. Are the securities which are the subject matter of this registration to be sold exclusively for cash? YES NO c. If not, furnish Exhibit C stating: (1) what will be received for such securities; (2) the number and class of securities to be exchanged therefore; (3) the names and addresses of the persons who will receive suc h securities; and (4) a sworn appraisal by a competent, disinterested, non - affiliated appraiser or such other proof as may be available with respect to the true value of items other than cash which will be received for such securities. American LegalNet, Inc. www.FormsWorkFlow.com Ohio Depar tment of Commerce FORM 6(A)(4) 11. NOTE: This form can be used only if items (a), (b) and (c) below can all be answered in the affirmative. a. Will the sale of the above described securities be made by a corporation? YES NO b. Are the above described securities to be offered exclusively to a class or classes of existing security holders of the above described issuer? YES NO c. Will the sales of the above described securities be made w ithout the payment, directly or indirectly, of any commission or other remuneration except as may be specified in (d) below? YES NO Answer (d), if applicable. If not applicable, so state. d. The above d iscount, commission or remuneration, if any, to be paid in connection with the offering and sale of the above described securities will be received by a securities dealer, who has agreed to purchase all securities not purchased by security holde rs to whom this offering is to be made. Attach and mark as Exhibit D a copy of the proposed agreement with such dealer. 12. Attached hereto and made a part of this filing are the following exhibits: Exhibit A e footnotes and profit and loss statement for the most recent fiscal year and the most recent fiscal quarter either audited or attested to by an executive officer if the issuer has engaged in business more than 90 days prior to the date of this registratio n. Exhibit B A specimen of the security to be sold pursuant to this registration. Exhibit C Referred to in Item 10(b) with respect to valuation of items other than cash to be received for securities. Exhibit D Referred to in Item 11(d) requiring c Exhibit E If issuer is not domiciled in Ohio, attach Form 11. (See R.C. Section 1707.11.) Exhibit F A prospectus must be attached if the aggregate amount of this offering exceeds $250,000. 13. Correspondence and the Certificate of Acknowledgment for this registration should be addressed to: (Name) (Street and Number) (City, State and Zip) (Phone) (Facsimile) SIGNATURE Issuer By American LegalNet, Inc. www.FormsWorkFlow.com Ohio Department of Commerce FORM 6(A)(4) VERIFICATION (Verification by One Person is Sufficient) County of State of The undersigned, being first duly sworn, deposes and says: That he has executed the foregoing for, an on beh alf of, the applicant named therein; that he is of such applicant and is fully authorized to execute and file such application; that he is familiar with such application and the facts underlying such application; and that to the best of his knowledg e, information and belief, the statements made in such application are true and the documents submitted herewith are true copies of the original thereof. Subscribed and sworn to before me Signature of Person Sworn Office Held Month, Day and Year Signature of Notary Public A Certificate of Acknowledgment will be mailed at effectiveness in seven business days pursuant to R.C. Section 1707.08 if the registration by description is not suspended or refused pursuant to R.C. Sections 1707.13 or 1707.131. No form can be returned for correction, nor can a refund be made of filing fees. Submit completed registration together with $50.00 fee to : Division of Securities 77 South High Street 22nd Floor C olumbus, Ohio 43215 - 6131 COM 4653 4/11/19 American LegalNet, Inc. www.FormsWorkFlow.com