COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.INTRASTATE 6NY # ANNUAL REPORT (INTRASTATE) TO BE SUBMITTED PURSUANT TO SECTION 80.15 OF THE INTRASTATE FINANCING ACT REGULATIONS WITHIN FOUR (4) AFTER THE CLOSE OF THE FISCAL YEAR.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)1. Name of Issuer: 2. Address: 3. Period covered by report: From to 4. Is there attached, as required, a Balance Sheet and a Profit and Loss Statement? Yes [ ] No [ ]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TODoes such statement include an express opinion as to fairness of presentation and consistency of the data, by an independent public accountant? Yes [ ] No [ ]GREETINGS:If not, has an exemption been obtained under Regulation 80.15(d)? Yes [ ] No [ ] by letter dated.WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County of5. Is there attached, as required, a narrative report setting forth the material events of the period covered by the report? Yes [ ] No [ ]o'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theCourt in Witness, Honorableday of, 20 County,6. Is there attached, a statement setting forth in detail the use of all proceeds obtained as a result of any offering or issue of securities or from any refinancing, or indicating that no such funds were obtained? Yes [ ] No [ ] No such funds obtained during period. [ ] [If any such funds were obtained, show accounting details including amount credited to capital accounts, surplus, long-term debt, notes payable, etc. on a separate sheet, attached.](Attorney must sign above and type name below)7A. Is there attached, as required, a statement setting forth the names and addresses of, and the compensation and other transactions with, all officers and directors or general partners or principals, of the issuer? Yes [ ] No [ ]Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:B. During the period covered by this report, did any principal, partner, officer of director sell or otherwise dispose of or hypothecate any of the issuer's securities or were any loans or advances made by the issuer to such persons? Yes [ ] No [ ] 8. Has the issuer submitted, as required, to all owners of the issuer's securities, an annual report containing the item stated under 4, 5, 6 and 7? Yes [ ] No [ ]Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)9. During the period covered by this report, was any injunction, cease an desist order, or revocationof license or registration, obtained, or were any such actions or proceedings instituted, or were criminal proceedings of any nature instituted or convictions obtained against the issuer or any principal thereof? Yes [ ] No [ ] 10. If there is any additional information which is material, such as any change in the issuer's management, ownership, financial structure, business, or its main operating location(s), or affirmative answers to questions 6, 7B or 9, state details on a separate sheet. Is such sheet attached? Yes [ ] No [ ]. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TODate:By: Signature(title)GREETINGS:Printed Name & Title: Telephone Number (include Area Code):WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomTO: N.Y. STATE DEPT. OF LAW REAL ESTATE FINANCING BUREAU 120 BROADWAY NEW YORK, NY 10271Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com
|
Get this form for FREE as a print-only pdf
