SUBSCRIBED AND SWORN. TO before me, a notary public for and in the City of Tuguegarao, Province of Cagayan this _ day of _ 2021. The affiants, whom I identified through the above-indicated competent evidence of identity, personally signed the foregoing instrument before me and avowed under penalty of law to the whole truth of the contents of said instrument. Doc. No. _ ; Page No. ___ ; NOTARY PUBLIC
SUBSCRIBED AND SWORN. TO BEFORE ME ON THIS ________ DAY OF ____________________ 2019. Commission Expires:______________ _________________________ Notary Public EXHIBIT D TO: Vista Capital Investments, LLC FROM: Blackboxstocks, Inc. DATE: July 17, 2019 RE: Disbursement of Funds Pursuant to that certain Fixed Convertible Promissory Note between the parties listed above and dated July 17, 2019, a disbursement of funds will take place in the amount and manner described below: Please disburse to: Amount to disburse: $150,000 Form of distribution Wire Name Blackboxstocks, Inc. Company Address 5000 XXX Xxxxxxx, Xxxxx 0000 Xxxxxx, Xxxxx 00000 Wire Instructions: Bank: Bank of America ABA Routing Number: 000000000 Account Number: 488052527580 SWIFT Code: FXXXXX0X Account Name: Blackboxstocks Inc Phone:900-000-0000 TOTAL: $150,000 For: Blackboxstocks, Inc. By: _________________________________________ Dated: July 17, 2019 Name: Gxxx Xxxxxx Its: President and Chief Executive Officer EXHIBIT E COMPANY CAPITALIZATION TABLE AS OF JULY 17, 2019 COMMON STOCK AND COMMON STOCK EQUIVALENTS ISSUED, OUTSTANDING AND RESERVED DESCRIPTION AMOUNT Authorized Common Stock Authorized Capital Stock 110,000,000 Authorized Common Stock 100,000,000 Issued Common Stock 7,715,551 Outstanding Common Stock 7,715,551 Treasury Stock n/a *Authorized, but unissued 141,027. Authorized Preferred Stock 10,000,000 Issued Preferred Stock 5,000,000 Reserved for Equity Incentive Plans n/a Reserved for Convertible Debt 4,230,769 Reserved for Options and Warrants** 65,385 Reserved for Other Purposes n/a TOTAL COMMON STOCK AND COMMON STOCK EQUIVALENTS OUTSTANDING 12,151,732 * Recently sold but unissued shares of Common Stock (Post Reverse Split) ** Recently sold but unissued Warrants to purchase shares of Common Stock (Post Reverse Split) Note: If not applicable, enter “n/a” or “zero” in Column 2. CURRENT DEBT AND LIABILITIES TABLE CONVERTIBLE PROMISSORY NOTE BALANCES AND PROMISSORY NOTE BALANCES DESCRIPTION ISSUANCE DATE AMOUNT Convertible Promissory Note 5-21-2019 $385,000 Promissory Note Txxxxxxx X. Xxxx 12-06-2018 $107,331.50 Gxxx Xxxxxx 12-06-2018 $108,000.00 Gxxx Xxxxxx 11-09-2018 $129,863.01 Other Debt and Liabilities Accounts Payable $553,668.07
SUBSCRIBED AND SWORN to before me this ___ day of December, 1997. ------------------------------------------- (Signature of Notary) ------------------------------------------- (Print or stamp name of Notary) NOTARY PUBLIC in and for the State of Washington, residing at _______________. My Appointment Expires: __________________. STATE OF WASHINGTON ) ) ss. COUNTY OF KING ) On this ___ day of December, 1997, before me, a Notary Public in and for the State of Washington, duly commissioned and sworn, personally appeared Xxxxxx X. Xxxxxx and Xxxxx X. Xxxxxxxx, to me known to be the Treasurer and the Secretary, respectively, of PUGET SOUND ENERGY, INC., one of the corporations that executed the within and foregoing instrument, and acknowledged the said instrument to be the free and voluntary act and deed of said corporation for the uses and purposes therein mentioned, and on oath stated that they were authorized to execute and attest said instrument, and that the seal affixed is the corporate seal of said corporation.
SUBSCRIBED AND SWORN to before me by Xxxxxx X. Xxx Xxxx, Xx. on this ____ day of _______, 200__. __________________________________________ Notary Public, State of ________ __________________________________________ Xxxxxxxxxxx X. Xxxxx SUBSCRIBED AND SWORN to before me by Xxxxxxxxxxx X. Xxxxx on this _______ day of ________, 200__. __________________________________________ Notary Public, State of ________
SUBSCRIBED AND SWORN. TO before me by Xxxxxxx Xxxxx, Mayor for the City of Hopkinsville on this the day of , 20 . NOTARY PUBLIC, KY STATE AT LARGE My Commission Expires: (SEAL) Prepared By: Xxxx X. Xxxxxx Christian County Attorney 000 Xxxx 00xx Xxxxxx PO Box 24 Hopkinsville, KY 42241-0024
SUBSCRIBED AND SWORN. BEFORE ME ON THIS THE _____ DAY OF ______________________, 20__ ________________________________________ [NOTARY SEAL] Notary Public My Commission Expires: ___________________ STATUTORY AFFIDAVIT Project Number and Name: Construction Professional: STATE OF GEORGIA; COUNTY OF : KNOW ALL MEN BY THESE PRESENTS: In reference to the Construction Agreement dated , 20 , between (Name of Construction Professional) and the Georgia State Financing and Investment Commission, the Construction Professional certifies as follows: All work required under the Construction Agreement has been performed in accordance with the terms thereof except as listed on attached Schedule A. Check if Schedule A is attached All materialmen, Trade Contractors, mechanics, and laborers have been paid and satisfied in full except as listed on attached Schedule B. Check if Schedule B is attached There are no outstanding claims of any character [including disputed claims or any claims to which the Construction Professional has or will assert any defense] arising out of the performance of the Construction Agreement that have not been paid and satisfied in full except as listed on attached Schedule C. Check if Schedule C is attached To the best of his knowledge and belief there are no unsatisfied claims for damages resulting from injury or death to any employees, Trade Contractors, or the public at large arising out of the performance of the contract, or any suits or claims for any other damage of any kind, nature, or description except as listed on attached Schedule D. Check if Schedule D is attached The undersigned makes this affidavit for the purpose of receiving payment for material completion; or, in the case of final payment for full settlement of all claims against the Owner arising under or by virtue of the Construction Agreement except as stated above. Acceptance of such payment is acknowledged as a release of the Owner from any and all claims arising under or by virtue of the Agreement except as stated above. This Affidavit is executed by the Construction Professional this day of , 20 . _____________________________________________, (Title) (Legal Signature) (Name of Construction Professional Firm)
SUBSCRIBED AND SWORN. BEFORE ME ON THIS THE _____ DAY OF ______________________, 20__ ________________________________________ [NOTARY SEAL] Notary Public My Commission Expires: ___________________ FIVE YEAR BOND ON ROOFS AND WALLS Project Number and Name: Construction Professional: Design Professional: STATE OF GEORGIA; COUNTY OF : Firmly Bound. Know all men by these presents, that we (CONSTRUCTION PROFESSIONAL) as Principal, and , as Surety, are held and firmly bound unto the Georgia State Financing and Investment Commission (Owner), in the sum of Dollars ($ ) for the payment of which will and truly to be made and done, we bind ourselves, our executors and administrators, our successors and assigns, jointly and severally, by these presents. Condition of Obligation. The condition of the above obligation is such that WHEREAS CONSTRUCTION PROFESSIONAL has entered into a Contract with Owner dated for construction of Project No. .
