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First Notice Of Transaction Pursuant To Corporations Code Section 25102(n) DBO-25102 N - California

First Notice Of Transaction Pursuant To Corporations Code Section 25102(n) Form. This is a California form and can be used in Securities Regulation Division Blue Sky Secretary Of State .
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STATE OF CALIFORNIA ­DEPARTMENT OF BUSINESS OVERSIGHT DBO ­25102 (n) (Rev. 07-13) FIRST NOTICE OF TRANSACTION PURSUANT TO CORPORATIONS CODE SECTION 25102 (n) (Department of Business Oversight Use Only) Fee paid $__________________________ Receipt No. _________________________ DEPARTMENT OF BUSINESS OVERSIGHT FILE NO., if any: _________________________________________ Insert File Number(s) of Previous Filings Before the Department, if any Check One: ( ) Transaction under Section 25102(n) ( ) Transaction under Rule 260.103 with Notice pursuant to Section 25102(n) FEE: $600.00 (For Section 25102(n) filings including transactions under Section 25102(n) and Rule 260.103) See Corporations Code Section 25608(x) 1. 2. Name of Issuer: Address of Issuer: _____________________________________________________________________ Street City State ZIP Mailing Address: Street 3. 4. Area Code and Telephone Number: Incorporation or organization of the Issuer. Check one: () () Issuer is a California corporation. Issuer is a foreign corporation subject to Corporations Code Section 2115. Issuer's state (or other jurisdiction) of incorporation or organization: . Issuer is another form of business entity organized under the laws of California (specify): . 5. 6. 7. Title of class or classes of securities to be sold in the transaction: Type of filing under Securities Act of 1933, if applicable: Distribution of Disclosure Statements. Check one: () Disclosure statements will be provided to each purchaser at least five business days before the securities are sold to the purchaser; or Disclosure statements will not be provided based on the fact that all purchasers fall within Rule 206.102.13. City State ZIP () () American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA ­ DEPARTMENT OF BUSINESS OVERSIGHT DBO ­ 25102 (n) (Rev. 07-13) Page 2 of 2 FIRST NOTICE OF TRANSACTION PURSUANT TO CORPORATIONS CODE SECTION 25102 (n) 8. Filing of Disclosure Statements. Check one: ( )Copies of the disclosure statements and subscription agreements are attached; or () Copies of the disclosure statements and subscription agreements will be filed with the Commissioner within 10 days of filing this notice. Failure to comply with this request may result in an administrative penalty of up to $1,000. 9. General Announcement of the Offering. Check one: () () A general announcement of the offering was not made and will not be made. A copy of the general announcement of the offering is enclosed with this notice. Date of Publication: Method of Publication (e.g., newspaper, other publications, Internet): _________________________________________________________ 10. Undertaking: The issuer undertakes to deliver the disclosure statement required by paragraph (4) of Corporations Code Section 25102(n) to be delivered to specified qualified purchasers, and any supplement thereto, to the Commissioner within 10 days of the Commissioner's request for the information. 11. Date of First Notice: Issuer () Check if issuer already has a consent to service of process on file with the Commissioner. Authorized Signature on behalf of Issuer Print name and title of signatory Name, Address, and Phone number of contact person: _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Instruction: Each issuer (other than a California Corporation) filing a notice under Section 25102(n) must also file a Consent to Service of Process (Form 260.165), unless it already has a valid consent to service on file with the Commissioner. American LegalNet, Inc. www.FormsWorkFlow.com
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