Quarterly Report Form {SC-610-044}

STATE OF WASHINGTON FOR VALIDATION ONLY Department of Financial Institutions Securities Division PO Box 9033 Olympia, WA 98507-9033 360-902-8760 QUARTERLY REPORT FORM NUMBER ______________________ REGISTRATION IN THE NAME OF _______________________________________ _______________________ ______________________________________________________________ AUTHORIZING THE SALE AND DISTRIBUTION OF _______________________________ ____________________ ___________________________________________________ 1. THE FOLLOWING REPORT IS FOR THE QUARTER ENDING __________________________, 19 ______ . 2. SECURITIES SOLD: NO. OF SHARES/UNITS DOLLAR AMOUNT THIS QUARTER ______________________________ ______________________________ PRIOR QUARTERS ______________________________ ______________________________ TOTAL TO DATE ______________________________ ______________________________ ON A SEPARATE SHEET LIST ALL INVESTORS SOLD THIS QUARTERS SHOWING THE AM OUNT BOUGHT BY EACH INVESTOR AND DATE OF PURCHASE (EXHIBIT A). 3. SELLING COST: AMOUNT PERCENT OF SALES THIS QUARTER ______________________________ ______________________________ PRIOR QUARTERS ______________________________ ______________________________ 4. IMPOUND (IF APPLICABLE) IMPOUND AGENT (Bank-Savings & Loan, etc.) ____________________________ _____________________ ADDRESS ________________________________________________________________ _______________ TOTAL AMOUNT OF IMPOUND TO BE REACHED __________________________________ ____________ DATE IMPOUND EXPIRES ___________________________________________________ ______________ AMOUNT IMPOUNDED THIS QUARTER . . . . . . . . . . . . . . . . . . . . .$ ________________________ AMOUNT IMPOUNDED PRIOR QUARTER . . . . . . . . . . . . . . . . . . . . .$ ________________________ TOTAL IN IMPOUND ACCOUNT TO DATE . . . . . . . . . . . . . . . . . . . . .$ ________________________ American LegalNet, Inc.SC-610-044 QUARTERLY REPORT (R/10/91) Page 1 of 2 www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 QUARTERLY REPORT FORM 5. FINANCE STATEMENT (*ATTACH AS EXHIBIT B) A. BALANCE SHEET* B. PROFIT AND LOSS STATEMENT* 6. OFFERING CIRCULAR OR PROSPECTUS (CHECK ONE) NO MATERIAL CHANGES HAVE OCCURRED SINCE THE LAST OFFERING CIRCULAR FILED . MATERIAL CHANGES HAVE OCCURRED REQUIRING REVISION OF LAST OFFERING CIRCU LAR FILED. A COPY OF THE PRESENT CIRCULAR, RED-LINED AS TO CHANGES, IS ENCLOSED FOR APPROVAL. 7. I CERTIFY THAT ALL THE ABOVE STATEMENTS AND DATA ARE TRUE, CORRECT, AND COMPLETE. DATE __________________________________________ BY ____________________ _______________________ A FILING FEE OF $10.00 MUST BE SUBMITTED WITH THIS REPORT. MAKE CHECKS P AYABLE TO STATE TREASURER On this ______________ day of ___________________, A.D. 19 _____, before me, the undersigned, a Notary Public in and for the State of __________________________________, duly commiss ioned and sworn, personally appeared to me known to be the above-named individual. Witness my hand and official seal hereto affixed the day and year in thi s certificate above written. _________________________________________________ Notary Public in and for the state of __________________________ residing at ______________ American LegalNet, Inc.SC-610-044 QUARTERLY REPORT (R/10/91) Page 2 of 2 www.USCourtForms.com