Stock Ledger and Capitalization Summary

[Name of company]
[name of company]
A [state where company incorporated] Corporation

Capitalization Summary
Name
Options for Common Stock Warrants for Common Stock Series A
Preferred Stock Series B
Preferred Stock Total

Total Issued and Outstanding
Total Authorized

[name of company]
A [state where company incorporated] Corporation

Common Stock Ledger

Certificate #
Number of Shares Shareholder and Address Original Date of Issuance Consideration Paid Per Share Comments / History / Transfers

[name of company]
A [state where company incorporated] Corporation

Stock Options Ledger

Optionee Name
and Address Number of Shares Exercisable Date of Option Agreement Vesting Schedule Exercise Price Comments / History / Transfers

[name of company]
A [state where company incorporated] Corporation

Warrants Ledger
Warrant # Number of Shares Exercisable Warrant holder and Address Date of Warrant Expiration Date of Warrant Exercise Price Comments / History / Transfers

[name of company]
A [state where company incorporated] Corporation

Series A Preferred Stock Ledger
Certificate # Number of Shares Shareholder and Address Original Date of Issuance Consideration Paid Per Share Comments / History / Transfers

[name of company]
A [state where company incorporated] Corporation

Series B Preferred Stock Ledger
Certificate # Number of Shares Shareholder and Address Original Date of Issuance Consideration Paid Per Share Comments / History / Transfers