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Registration By Qualification Quarterly Report SD-71 - Indiana

Registration By Qualification Quarterly Report Form. This is a Indiana form and can be used in Securities Blue Sky Secretary Of State .
 Fillable pdf Last Modified 11/7/2006
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FORM #SD-71 ISSUERS NAME (Rev. 4/93) REGISTRATION NUMBER State Form 11442 (R2/4-93) STATE OF INDIANA OFFICE OF THE SECRETARY OF STATE Securities Division 302 West Washington St., Room E-111 Indianapolis, Indiana 46204 FOR CALENDAR QUARTER ENDING: REGISTRATION BY QUALIFICATION QUARTERLY REPORT Required by 710 IAC 1-11-2 To be filed within 45 days from end of quarter This report must be filed within 45 days of the end of each calendar quarter as long as the registration is effective. Use a separate form for each registration of different types or classifications of securities. (Form SD-75 must also be filed within 90 days of the end of the issuers fiscal year. Form SD-76 must be filed as soon as possible after the close of the offering.) ISSUERS NAME: ISSUERS ADDRESS: Description and amount of securities registered: 1. Dollar sales in Indiana during quarter..............$ 2. Units sold in Indiana during quarter................$ 3. Number of Indiana purchasers........................$ 4. Additional amount registered during quarter.........$ 5. Total dollar sales to the close of the quarter......$ 6. Total units sold to the close of the quarter........$ 7. Total number of purchasers of securities during the quarter................................. $ List all registered broker-dealers participating or agents of the issuer registered since the last report: Describe any material changes to the prospectus currently on file with the Division. If the proceeds from the sales were required to be impounded, have any funds been released? If so, the dollar amount during the quarter? I hereby verify that the statements made in this report are true. DATE: SIGNATURE OF OFFICER PRINTED SIGNATURE TITLE 1868m American LegalNet, Inc. www.USCourtForms.com
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