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STATE OF UTAH
DEPARTMENT OF COMMERCE
DIVISION OF SECURITIES
FORM 9-1

Closing Report: Registration by Coordination

Date: _______________________________

Utah Entity No.______________________

Utah File No.________________________

Name of Issuer:______________________________________________________

Address: ____________________________________________________________

City: ____________________ State: ___________________ Zip: _____________

1. Total of issue offered in all states:

A)Total number of securities:

B)Total dollar amount of securities:

2. Total sales made in all states:

A) Total number of securities:

B) Total dollar amount of securities:

3. Total of issue registered in Utah:

A) Total number of securities:

B) Total dollar amount of securities:

4. Total sales made in Utah:

A) Total number of securities:

B) Total dollar amount of securities:

By:_______________________________________

Title:______________________________________