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Private Placement Report Form NJBOS-1 - New Jersey

Private Placement Report Form Form. This is a New Jersey form and can be used in Securities Blue Sky Secretary Of State .
 Fillable pdf Last Modified 9/30/2005
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NEW JERSEY BUREAU OF SECURITIES Post Office Box 47029, Newark, NJ 07101 th 153 Halsey Street, 6 Floor, Newark, NJ 07102 (973) 504-3600 Private Placement Report Form N.J.S.A. 49:3-50(b)(12) A manually signed copy of this form shall be filed with the Bureau no later than 15 days after the first sale of securities in New Jersey. This form need not be notarized. A manually signed Form U-2 (Uniform Consent to Service of Process) shall be filed; the Chief of the Bureau of Securities shall be designated on Form U-2. A copy of the Offering Statement or Prospectus shall be filed. The fee is $250.00, payable to New Jersey Bureau of Securities. The che ck need not be certified. A private placement under Section 50(b)(12) is limited to 35 investors in any 12-month period. Accredited investors and investors residing outside New Jersey shall be excluded from the calcu- lation of this limit. Accredited investor is defined in N.J.S.A. 49:3-49(p). Supplemental reports shall be filed promptly after the initial filing with the Bureau, whenever there are material changes to the information contained in the initial filing until the closing of the offering. A final report shall be filed at the closing of the offering, if the information in the final report would be materially different from the last prior filing. Additional sales to non-accredited New Jersey investors are material. The securities shall not be offered or sold by general solicitation or general advertisement. If this offering is being sold by agents of the issuer, such agents need not be registered with the Bureau. If this offering is being sold by agents of a broker-dealer, bo th the agents and the broker-dealer shall be registered with the Bureau. 1. DESCRIPTION OF ISSUER: a. Type of entity: Corporation _____ LLC _____ Other (specify) __________ _________________ b. Name: _______________________________________________________________ c. Address: ________________________________________________________ ______ d. State of formation: ______________________________________________________ American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2New Jersey Private Placement Report Form, Page 2 e. Officers, directors, general partners, and control persons: Name and address Position or Control persons affiliation form of control ___________________________ ___________________ ___________________ ___________________________ ___________________ __________ _________ ___________________________ ___________________ ___________________ ___________________________ ___________________ ___________________ ___________________________ ___________________ ___________________ ___________________________ ___________________ ___________________ ___________________________ ___________________ ___________________ Note: New Jersey uses a common-law definition of control. 2. NEW JERSEY NON-ACCREDITED PURCHASERS: (Attach additional sheets if necessary.) Name and address: No. of Total purchase units: price: _____________________________________ _______ $__________________ _____________________________________ _______ $__________________ _____________________________________ _______ $__________________ _____________________________________ _______ $__________________ _____________________________________ _______ $__________________ _____________________________________ _______ $__________________ _____________________________________ _______ $__________________ Totals _______ $__________________ American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3New Jersey Private Placement Report Form, Page 3 3. DESCRIPTION OF SECURITIES: a. Type (common stock, bonds, etc.): ____________________ Price per unit: $_______ b. SEC exemption: Section 4(2) _______ Rule 504 _______ Rule 505 ___ ____ c. Total amt. of offering (NJ and elsewhere, accredited and otherwise): $________ ____ d. Total # of purchasers (NJ and elsewhere, accredited and otherwis e): _____________ 4. DATE OF FIRST SALE IN NEW JERSEY: __________________________________ 5. BROKER-DEALER EFFECTING TRANSACTIONS: (Omit this section if no broker-dealer is involved in offers or sales.) a. Name of broker-dealer: __________________________________________________ b. Central Registration Depository number of broker-dealer: _______________________ c. Address of broker-dealer: _______________________________________ _________ d. Manner of compensation of broker-dealer: ___________________________________ e. Amount of compensation of broker-dealer: $__________________________________ f. Is broker-dealer registered in New Jersey? ____________________________________ g. Name of agent: ________________________________________________________ h. Central Registration Depository number of agent: _____________________________ i. Is agent registered in New Jersey? __________________________________________ 6. CERTIFICATION: I certify that the foregoing statements are true. I am aware that if any of the foregoing statements are willfully false, I am subject to punishment. Name of Issuer: _____________________________ Date: ____________________ By: _______________________________________ Telephone: _______________ Title: _____________________________________ Fax: _____________________ Form NJBOS-1, 6/2003 American LegalNet, Inc. www.USCourtForms.com
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