72-101F1 - Report of a trade under section 2.4 of Multilateral Instrument 72-101 Distributions Outside of the Local Jurisdiction [F Proposed - Lapsed]

Note: This report is not required where a bank listed in Schedule I or II to the Bank Act (Canada) or a loan corporation or trust corporation registered under the Loan and Trust Corporation Act acquires from a customer an evidence of indebtedness of the customer or an equity investment in the customer acquired concurrently with an evidence of indebtedness.

1. Full name, address and telephone number of the Issuer/Selling Securityholder.

2. Describe the type of security, the aggregate number or amount distributed and the aggregate purchase price.

3. State whether or not the issuer of the security distributed is a qualifying issuer as defined in Multilateral Instrument 72-101.

4. Date of distribution(s).

5. State the name and address of each purchaser, the number or amount of securities purchased and the purchase price paid by each purchaser. Attach list if necessary.

6. State the name and address of any person acting as agent in connection with the distribution(s) of the securities and the compensation paid or to be paid to the agent and the name(s) of the purchaser(s) in respect of which the compensation was paid or is to be paid.

7. After exercising reasonable diligence in its enquiries, the issuer/selling securityholder believes that the issuer/selling securityholder is eligible to use section 2.4 of Multilateral Instrument 72-101.

Certificate of Issuer/Selling Securityholder

The undersigned hereby certifies that the statements made in this report are true.


DATED: _______________, 20__

________________________________________________
(Name of Issuer/Selling Securityholder)


________________________________________________
(Signature of Authorized Signatory)


________________________________________________
(Name and Office of Authorized Signatory)

Instruction:

1. In answer to question 6 compensation includes commissions, discounts or other fees or payments of a similar nature directly related to the distribution of the securities. It is not necessary to include payments for services incidental to the distribution such as clerical, printing, legal or accounting services.