Cooperative Mutual Associations Notification Of Claim Exemption {RCW 21.20.320(16)(A)(II)}

Cooperative / Mutual Associations Notification of Claim of Exemption pursuant to RCW 21.20.320(16)(a)(ii) Date Name of Issuer State and Date of Incorporation Address TelephoneCity, State, Zip Code 1. Description of security to be offered: Price per security: Number of securities to be offered: 2. Please indicate below the name, address, and telephone number of each cu rrent officer and director of the issuer. 3. Pursuant to RCW 21.20.320(16)(b)(i), the issuer hereby represents that the securities: A. Qualify a holder to be a member or patron of the association; B. Represent a contribution of capital to the association by persons who ar e or intend to become members or patrons of the association; C. Represent a patronage dividend or other patronage allocation ; or D. Represent the terms or conditions by which members or patrons purchase, sell, or market products, commodities, or services from, to, or through the assoc iation. Notice of Claim of Exemption Pursuant to RCW 21.20.320(16)(a)(ii) - 1 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 24. The issuer further represents that the securities are nontransferable ex cept in the case of death; operation of law; bona fide transfer for security purposes to the association, a bank, or transfer to an existing member or person who will become a member and , in the case of an instrument, that said restriction is conspicuously stated on its face . The issuer represents that it meets the requirements for exemption from registration pursuant to RCW 21.20.320(16). The issuer acknowledges that the filing of this notice does not relieve it from compliance with the full disclosure and anti-fraud provisions of RC W 21.20.010. Date ______ day of _______________, 19___. ________________________________________________ Signature of Issuer Representative ________________________________________________ Print name of Representative ________________________________________________ Title of Representative Subscribed and sworn to before me this ______ day of ______________, 19_ __. ________________________________________________ Notary Public in and for the State of Washington residing at ________________________________________________ Notice of Claim of Exemption Pursuant to RCW 21.20.320(16)(a)(ii) - 2 American LegalNet, Inc. www.USCourtForms.com