Nevada > Secretary Of State > Blue Sky > Securities Division
Year End Securities Sales Report 500-3 - Nevada
| Year End Securities Sales Report Form. This is a Nevada form and can be used in Securities Division Blue Sky Secretary Of State . |
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ROSS MILLER Secretary of State 555 East Washington Ave., #5200 Las Vegas, Nevada 89101 Phone (702) 486-2440 Fax (702) 486-2452 Website: www.nvsos.gov Nevada Form 500-3 Year End Securities Sales Report ABOVE SPACE FOR OFFICE USE ONLY Date: 1. The undersigned hereby files a fiscal year end securities report pursuant to NRS 90.500 paragraph 3. 2. The following information is submitted: Name of Issuer Address of Issuer Street or Mailing Address City State Zip Code Fiscal Year End: Nevada Securities Division File No.: 3. I understand that this form must be accompanied by a filing fee of 0.2% of the maximum aggregate offering price at which the registered securities are to be offered in this State, but no less than $700.00 or more than $5,000.00. I also understand that this year end fee is in addition to whatever fee was filed with the initial registration statement. a. b. The aggregate sale price of the securities sold under this registration to persons in Nevada during the previous fiscal year was: The following fee is enclosed in the form of a check payable to SECRETARY OF STATE, SECURITIES DIVISION: USD $ USD $ 4. The following information is submitted: Effective date: Expiration date: Aggregate amount available for sale in Nevada: USD $ Total amount sold in Nevada: USD $ 5. I understand that no acknowledgment of this filing will be made unless one additional copy of this notice and a self-addressed, stamped envelope are submitted with this form. 6. Submitted by: Name of Submitter Address of Submitter Street Address City State Zip Code Telephone: NOTE: In order for your report to be processed, this form must be filled out completely. Incomplete forms will be returned. Nevada Secretary of State Securities Form 500-3 American LegalNet, Inc. www.FormsWorkFlow.com Revised 12-23-10
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