Debenture Company Quarterly Report Form

STATE OF WASHINGTON Department of Financial Institutions Securities Division P.O. Box 9033 Olympia, WA 98507-9033 Telephone: (360) 902-8760 Fax: (360) 586-5068 DEBENTURE COMPANY QUARTERLY REPORT FORM FOR VALIDATION ONLY Permit Holder: Permit No.: Permit Effective Date: 1. This report is for the quarter ended: 2. Securities sold under CURRENT permit: Dollar Amount This month: Prior months: Total to Date: 3. Debenture Maturity Analysis Amount Due Within: 30 days 90 days 1 year 2 years Longer Total Outstanding: 4. Loans to One Borrower (Check One): There are no loans outstanding to any one borrower that exceed 2.5% of the Company's assets. A separate list is attached detailing loans to any one borrower that exceed 2.5% of the Company's assets. Dollar Amount Percentage Permit Amount: Permit Expiration Date: Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 5. Investments in Unsecured Loans: Amount of Investments in Unsecured Loans: Attach a separate sheet listing the Company's investments in unsecured loans. 6. Financial Statements: Attach a balance sheet and profit and loss statement prepared in accordance with generally accepted accounting principles for the period being reported. 7. Offering Circular or Prospectus (Check One): No material changes since the last offering circular was filed. Material changes have occurred requiring revision of the last offering circular filed. A copy of the current offering circular, showing red-lined changes, is enclosed with this report for approval. 8. I certify that all the above statements and data are true, correct, and complete. Date: Signature: Title: A FILING FEE OF $10.00 MUST BE SUBMITTED WITH THIS REPORT. MAKE CHECKS PAYABLE TO "STATE TREASURER." General Reminders Loans and Investments Limitations: Pursuant to RCW 21.20.820, debenture companies may not make loans to any one borrower that exceed 2.5% of the assets of the debenture company. RCW 21.20.830 stipulates that a debenture company may not invest more than 20% of its assets in unsecured loans. In addition, RCW 21.20.815 stipulates that debenture companies shall not make equity investments in a single project or subsidiary that exceed 10% of its assets or of more than its net worth, whichever is greater, and the total of all equity investments must not exceed 20%. Revision of Offering Circular: In accordance with WAC 460-16A-126, upon any material change in the information contained in the offering circular, the issuer must file an amended offering circular with the Division. Pursuant to WAC 460-28A-015, prior to disseminating any advertising materials to the public, every debenture company must file the proposed advertising materials with the Division five days prior to use. Advertising: Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Financial Statements: In connection with RCW 21.20.740 and RCW 21.20.210, debenture companies must file annually audited financial statements prepared in accordance with generally accepted accounting principles within 120 days after the close of the period. In addition, debenture companies must file quarterly financial statements complete with footnotes and prepared in accordance with generally accepted accounting principles. Quarterly financial statements are not required to be audited and must be submitted within 30 days of the close of the period. Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com