| Item No. | 1 |
|---|---|
| Lender's Name | |
| Lender's Title | |
| Relationship to Insider | |
| Original Amount of Loan | |
| Balance Due | 193,567 |
| Date of Note | |
| Maturity Date | |
| Repayment Terms | |
| Interest Rate | |
| Security Provided by Borrower | |
| Purpose of Loan | |
| Description of Lender Consideration | |
| Consideration FMV |