| UNITED STATES SECURITIES |
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| 1. Issuer's Identity | |||||||||||||||
| CIK (Filer ID Number) | Previous Name(s) |  | None | Entity Type | |||||||||||
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| Name of Issuer | |||||||||||||||
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| Jurisdiction of Incorporation/Organization | |||||||||||||||
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| Year of Incorporation/Organization | |||||||||||||||
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| 2. Principal Place of Business and Contact Information | |||||
| Name of Issuer | |||||
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| Street Address 1 | Street Address 2 | ||||
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| City | State/Province/Country | ZIP/Postal Code | Phone No. of Issuer | ||||
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| 3. Related Persons |
| Last Name | First Name | Middle Name | ||
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| Street Address 1 | Street Address 2 | ||
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| Clarification of Response (if Necessary) | |
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| Last Name | First Name | Middle Name | ||
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| Street Address 1 | Street Address 2 | ||
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| Clarification of Response (if Necessary) |
| Last Name | First Name | Middle Name | ||
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| Street Address 1 | Street Address 2 | ||
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| Clarification of Response (if Necessary) |
| Last Name | First Name | Middle Name | ||
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| Street Address 1 | Street Address 2 | ||
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| Clarification of Response (if Necessary) |
| Last Name | First Name | Middle Name | ||
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| Street Address 1 | Street Address 2 | ||
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| Clarification of Response (if Necessary) | |
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| 4. Industry Group |
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| 5. Issuer Size |
| Revenue Range | Aggregate Net Asset Value Range | ||
 | No Revenues | | No Aggregate Net Asset Value |
| | $1 - $1,000,000 | | $1 - $5,000,000 |
| | $1,000,001 - $5,000,000 | | $5,000,001 - $25,000,000 |
| $5,000,001 - $25,000,000 | | $25,000,001 - $50,000,000 |
| $25,000,001 - $100,000,000 | | $50,000,001 - $100,000,000 |
| | Over $100,000,000 | | Over $100,000,000 |
 | Decline to Disclose | | Decline to Disclose |
| | Not Applicable | | Not Applicable |
| 6. Federal Exemption(s) and Exclusion(s) Claimed (select all that apply) |
| Rule 504(b)(1) (not (i), (ii) or (iii)) |  Rule 506(b) | |||||
| Rule 504 (b)(1)(i) | Rule 506(c) | |||||
| Rule 504 (b)(1)(ii) | Securities Act Section 4(a)(5) | |||||
| Rule 504 (b)(1)(iii) | Investment Company Act Section 3(c) | |||||
| 7. Type of Filing |
| | New Notice | Date of First Sale |
| | First Sale Yet to Occur |
| | Amendment |
| 8. Duration of Offering |
| Does the Issuer intend this offering to last more than one year? | | Yes | | No |
| 9. Type(s) of Securities Offered (select all that apply) |
| Pooled Investment Fund Interests | | Equity |
| Tenant-in-Common Securities | | Debt |
| Mineral Property Securities | | Option, Warrant or Other Right to Acquire Another Security |
| Security to be Acquired Upon Exercise of Option, Warrant or Other Right to Acquire Security | | Other (describe) |
| 10. Business Combination Transaction |
| Is this offering being made in connection with a business combination transaction, such as a merger, acquisition or exchange offer? | | Yes | | No | |
| Clarification of Response (if Necessary) | |||||
| 11. Minimum Investment |
| Minimum investment accepted from any outside investor | $ |
| USD | |
| 12. Sales Compensation |
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| State(s) of Solicitation | | All States | | Foreign/Non-US | |
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| 13. Offering and Sales Amounts |
| Total Offering Amount | $ |
| USD | | Indefinite | |
| Total Amount Sold | $ |
| USD | |||
| Total Remaining to be Sold | $ |
| USD | | Indefinite |
| Clarification of Response (if Necessary) | |
| 14. Investors |
| Select if securities in the offering have been or may be sold to persons who do not qualify as accredited investors, Number of such non-accredited investors who already have invested in the offering | ||
| Regardless of whether securities in the offering have been or may be sold to persons who do not qualify as accredited investors, enter the total number of investors who already have invested in the offering: |
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| 15. Sales Commissions & Finders’ Fees Expenses |
| Provide separately the amounts of sales commissions and finders' fees expenses, if any. If the amount of an expenditure is not known, provide an estimate and check the box next to the amount. |
| Sales Commissions | $ |
| USD | | Estimate | |
| Finders' Fees | $ |
| USD | | Estimate |
| Clarification of Response (if Necessary) | |
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| 16. Use of Proceeds |
| Provide the amount of the gross proceeds of the offering that has been or is proposed to be used for payments to any of the persons required to be named as executive officers, directors or promoters in response to Item 3 above. If the amount is unknown, provide an estimate and check the box next to the amount. |
| $ |
| USD | | Estimate |
| Clarification of Response (if Necessary) | |
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| Signature and Submission |
| Please verify the information you have entered and review the Terms of Submission below before signing and clicking SUBMIT below to file this notice. |
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| Terms of Submission |
| In submitting this notice, each Issuer named above is: | ||
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| Each Issuer identified above has read this notice, knows the contents to be true, and has duly caused this notice to be signed on its behalf by the undersigned duly authorized person. | ||||||||||||
| For signature, type in the signer's name or other letters or characters adopted or authorized as the signer's signature. | ||||||||||||
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