Canada Customs

and Revenue Agency

Agence des douanes

et du revenu du Canada

T100C
FLOW-THROUGH SHARE INFORMATION

APPLICATION FOR A T100 IDENTIFICATION NUMBER (TIN)

ON THE EXERCISE OF FLOW-THROUGH WARRANTS (FTWs) AND
DETAILS OF THE FTWs EXERCISED
z

If you need the instructions, ask for Form T100 Instructions for the Flow-through Share
Program or visit our Website at www.cra.gc.ca.

To request a TIN on the exercise of FTWs, complete this form.

A corporation filing Form T100C should send it directly to: Canada Revenue Agency,
Other Programs Unit, Data Assessment & Evaluation Programs Division, 875 Heron Road,
Ottawa ON K1A 1A2

Do not use this area

On this form, legislative references are to the Income Tax Act, and regulatory references are to the Income Tax Act Regulations.

The assignment of the identification number is for identification purposes only. It does not imply that the shares are flow-through shares,
that the agreement or the expenses meet all or any of the requirements of the Income Tax Act with respect to flow-through shares, or that
we accept the allocation of the price between the shares and the warrants. The corporation may be subject to an audit.

Complete Application Checklist

Filing a complete application will speed up its processing. Before sending your application, check if you have:
1. Used the current version of Form T100C for the application.
2. Signed and dated Form T100C in the "CERTIFICATION" area.
3. Provided a complete listing of the investors who exercised their FTWs in the format shown in Part 3.
4. Used the SITIN that was issued on the filing of Form T100A to identify the agreement to which the FTWs relate. The SITIN must not
be used to renonce expenditures for the FTWs identified on this form.

Part 1 General Information (please print)

Name of corporation

Corporation account number

R C
Corporation address

City

Mailing address (if different)

Province

Location of records (if different)

City

Postal code

same as corporation
same as mailing
Province

Postal code

City

Postal code

Province

Contact person and title

Telephone

FAX

Part 2 Exercise of the FTWs

Step 1 Identification number previously issued

Enter the identification number that was issued on the initial filing of Form T100A. The number is required for the Canada Revenue Agency
(CRA) to identify the agreement that is related to the exercise of the FTWs. The number issued for Form T100A must not be used to
renounce expenditures for the FTWs identified on this form.

Step 2 Information pertaining to the exercise of the FTWs

Actual number of FTWs exercised
Exercise price per FTW
Total proceeds from the exercise of the FTWs to be spent on eligible expenditures (45) X (46)
T100C E (04)

(Ce formulaire existe en franais.)

(45)
(46) $
(47) $

Part 3 List of investor who exercised their FTWs

No agent's name should appear in this list.
SIN , CORP. OR
PARTNERSHIP NO.

INVESTORS' NAME

DATE OF EXERCISE
(MM/DD/YYYY)

NUMBER OF FTWs
EXERCISED

TOTAL (TOTAL AMOUNT INVESTED must be equal to line 47)

If additional space is required, please attach a list using the same format as on this form.
No agent's name should appear in this list.
The renunciations should be made in the name of the shareholders and not the agent.

CERTIFICATION
I certify that the information given on this form is to the best of my knowledge, true, correct and complete in every respect.

Date (mm/dd/yyyy)

Signature of Authorized Officer

Printed in Canada

Name of Authorized Officer (Print)

Position or Title (Print)

TOTAL AMOUNT
INVESTED