Secretary of State 
                                                                Business Programs Division 
                                                                            Business Entities 
                                                   1500 11th Street, Sacramento, CA 95814 
                                               P.O. Box 944260, Sacramento, CA 94244-2600 

                                                   Submission Cover Sheet

For faster service, file online at bizfileOnline.sos.ca.gov               . 

Instructions: 

• Complete and include this form with your paper submission. This information only will be
  used to communicate in writing about the submission, if needed. This form will be
  treated as correspondence and will not be made part of the filed document.

• Make all checks or money orders payable to the Secretary of State.

• In person submissions (excluding Statements of Information): $15 handling fee; do not include
  a $15 handling fee when submitting documents by mail.

• Standard processing time for submissions to this office is approximately 5 business days from
  receipt. All submissions are reviewed in the date order of receipt with online submissions
  given priority. For updated processing time information, visit
  www.sos.ca.gov/business/be/processing-dates.

Optional Copy and Certification Fees: 

• If applicable, include optional certification fees with your submission.

• For applicable certification fee information, refer to the instructions of the specific form you are
  submitting.

Contact Person: (Please type or print legibly) 

First Name:                                      Last Name: 

Phone (optional):  

Entity Information: (Please type or print legibly) 

Name:  

Entity Number (if applicable):  

Address: 

Comments

Submission Cover Sheet (REV 03/2022)                            Clear Form  Print Form

                                                                               SI-PT 
                              Secretary of State 

                              Corporate Disclosure Statement 

                              (Domestic Stock and Foreign 
                              Corporations) 

 Filing Fee  –       There is no fee for filing the Corporate Disclosure Statement. 
 Certification Fee (Optional)    –      $5.00
                                                                                                   This Space For Office Use Only
  1.   Corporate Name (Enter the exact name of the corporation as it is recorded with the California Secretary of State.)

  2. Secretary of State Entity Number                        3. Jurisdiction (Enter the state, foreign country or other place where the corporation
                                                                is formed.)

 4.    Independent Auditor

  4a. Name of the Independent Auditor that prepared the most recent auditor’s report. 

  4b. Description    of other services, if any, performed by the Independent Auditor named in Item 4a. 

 4c. Name of the Independent Auditor employed by the corporation on the date of this statement, if different from Item 4a. 

  5.   Required Statutory Disclosures

 5a. Has an order for relief been entered in a bankruptcy case with respect to the corporation during the 
                                                                                                                                            Yes       No 
       preceding 10 years? 
  
 5b. Has the corporation or any of its subsidiaries been a party to, or any of their property been subject to, any 
       material pending legal proceedings, as specified by Item 103, Part 229 of SEC Regulation S-K? If yes,                                Yes       No 
       attach a description.
 5c. Has the corporation been found legally liable in any material legal proceeding during the preceding five 
                                                                                                                                            Yes       No 
       years? If yes, attach a description. 

                                                - CONTINUE ON NEXT PAGE -
                                                                 (Page 1 of 2) 

 SI-PT (REV01/2023)                             Clear Form                   Print Form                                    202 3California Secretary of State   
                                                                                                                                bizfileOnline.sos.ca.gov 

                                          Corporate Disclosure Statement 
                                          (Domestic Stock and Foreign Corporations) 
                                                                  (Page 2 of 2)
6.  Directors
      Names of Directors                        Compensation       Shares                   Options Bankruptcy        Fraud 
       1)                                                                                           Yes     No        Yes          No 
       2)                                                                                           Yes     No        Yes          No 
       3)                                                                                           Yes     No        Yes          No 
       4)                                                                                           Yes     No        Yes          No 
       5)                                                                                           Yes     No        Yes          No 
       6)                                                                                           Yes     No        Yes          No 
       7)                                                                                           Yes     No        Yes          No 
       8)                                                                                           Yes     No        Yes          No 
       9)                                                                                           Yes     No        Yes          No 
      10)                                                                                           Yes     No        Yes          No 
      11)                                                                                           Yes     No        Yes          No 
      12)                                                                                           Yes     No        Yes          No 
      13)                                                                                           Yes     No        Yes          No 
      14)                                                                                           Yes     No        Yes          No 
      15)                                                                                           Yes     No        Yes          No 
      16)                                                                                           Yes     No        Yes          No 

7.  Executive Officers                           
7a.   Names of Executive Officers               Compensation       Shares                   Options Bankruptcy        Fraud 
      1)                                                                                            Yes     No        Yes          No 
      2)                                                                                            Yes     No        Yes          No 
      3)                                                                                            Yes     No        Yes          No 
      4)                                                                                            Yes     No        Yes          No 
      5)                                                                                            Yes     No        Yes          No 

7b.   Chief Executive Officer (if not named in                    
    7a)                                          Compensation      Shares                   Options Bankruptcy        Fraud 
                                                                                                    Yes     No        Yes          No 

7c. Additional Executive Officers (if not named in  a7or  b)7
      1)                                                                                             Bankruptcy               Fraud 
      2)                                                                                             Bankruptcy               Fraud 
      3)                                                                                             Bankruptcy               Fraud 

8.  Loans to Members of the Board of Directors
      Names of Directors                        Description of Loan including Amount and Terms 
      1) 
      2) 

If additional space is needed, place the additional information on only one side of a standard letter-sized piece of paper (8 ½ x 11) 
clearly marked as an attachment to the Corporate Disclosure Statement and attach the extra page(s) to the completed Corporate 
Disclosure Statement. 
By submitting this Corporate Disclosure Statement to the Secretary of State, the corporation certifies the information contained herein, 
including any attachments, is true and correct. 

__________________________________________        _____________________________       ______________________     _________________ 
Type or Print Name of Person Completing the Form          Signature                         Title                    Date

SI-PT (REV 01/202  3)                                                                                            202 3California Secretary of State          
                                                Clear Form         Print Form                                         bizfileOnline.sos.ca.gov