Indiana > Secretary Of State > Blue Sky > Securities
Applicants Affidavit Of Termination Of Offering And Distribution Of Securities Registered In Indiana SD-76 - Indiana
| Applicants Affidavit Of Termination Of Offering And Distribution Of Securities Registered In Indiana Form. This is a Indiana form and can be used in Securities Blue Sky Secretary Of State . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
State Form 39859 R2 FORM: SD-76 ISSUERS NAME REVISED 3/87 REGISTRATION NO. STATE OF INDIANA OFFICE OF THE SECRETARY OF STATE SECURITIES DIVISION APPLICANTS AFFIDAVIT OF TERMINATION OF OFFERING AND DISTRIBUTION OF SECURITIES REGISTERED IN INDIANA (Required by 710 IAC 1-11-3, to be filed within 30 days after terminati on.) ISSUER: (a) Name: (b) Address of Principal Office: APPLICANT: (a) Name: (b) Address: (1) The Applicant has sold or caused to be sold in Indiana (number of units) of (description of security) ; consisting of an aggregate amount of $ (2) The securities are registered in Indiana by registration number ;(3) The Applicant: (check appropriate item) ( ) has fully sold or caused to be sold and distributed all of the securitie s registered in Indiana. ( ) no longer desires to offer for sale, sell or distribute in the State of Indiana the securities of the registered offering. (4) The following are the names and addresses of the persons or entit ies who are residents of the State of Indiana or are doing business in Indiana and p urchased, subscribed or otherwise acquired a right to 10% or more of the offering which was actually sold: (If none, so state.) (5) The Applicants registration in Indiana is now ineffective. I hereby verify that the statements contained herein are true. Applicant President or Vice-Presidents Signature Secretary or Assistant Secretarys Signature (Printed Name) (Printed Name) (NOTE : The requirement to file quarterly and annual reports pursuant t o 710 IAC 1-11-1 and 12 is terminated with the filing of this affidavit.) American LegalNet, Inc. www.USCourtForms.com
|
|||||||
