This Questionnaire is used when obtaining or verifying information so the company can complete annual reports to be filed with the Securities and Exchange Commission (SEC) (also known as a 10-K). This questionnaire will be used by directors, executive officers and shareholders who own 5% or more of the company's outstanding stock.

Requested information includes general information (i.e. name, date of birth and offices and positions held), business experience related to the company and if the individual has been convicted in a criminal proceeding. It also requests information regarding compensation paid in cash or bonuses and executive compensation other than cash.

This Questionnaire for Directors, Executive Officers and 5% or More Shareholders contains:

• Personal Information: Requests the full name, birth date and any company offices or positions held, as well as any family relationship with other directors or officers of the corporation;
• Experience: Brief account of experience during the last five years, including occupation and employment;
• Directorships: List of any directorships held by any other company registered with the SEC;
• Compensation: Information regarding any compensation or cash received for services rendered on behalf of the company;
• Executive Compensation: Requests information regarding deferred compensation, incentive and compensation plans and arrangements or stock purchase, profit sharing or other plans;
• Transactions with Management: Sets forth all transactions in which you have a direct or indirect interest;
• Indebtedness: Sets forth any indebtedness owed to the company;
• Signatures: This questionnaire must be signed and dated.

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This attorney-prepared packet contains:

1. General Information
2. Instructions and Checklist
3. Questionnaire for Directors, Executive Officers and 5% or More Shareholders

State Law Compliance: This form complies with the laws of all states