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Notification Filing 99 - New York

Notification Filing Form. This is a New York form and can be used in Investor Protection And Securities Blue Sky Secretary Of State .
 Fillable pdf Last Modified 9/5/2012
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OFFICE OF ATTORNEY GENERAL ERIC T. SCHNEIDERMAN STATE OF NEW YORK DEPARTMENT OF LAW File # _____ NY FORM 99 INVESTOR PROTECTION BUREAU / REAL ESTATE FINANCE BUREAU NOTIFICATION FILING Pursuant to National Securities Markets Improvement Act of 1996 ("NSMIA") Submission to: INVESTOR PROTECTION BUREAU ("IPB") REAL ESTATE FINANCE BUREAU ("REF") Securities Theatrical Syndications Type of Filing: New Filing Amendment or Renewal (If name, address or offering has changed, indicate change): A. BASIC IDENTIFICATION DATA Full Name of Issuer (and Theatrical Production Company, if applicable): Address of Executive Offices: Telephone Number ( ) _______ - ___________ ___________________________________ _____________________________ ___________________ (Number and Street) (City or Town) (State & ZIP) Type of Organization: business corporation limited liability company limited partnership not-for-profit corporation business trust political subdivision of state common fund state agency or authority county, city, town or village ( agency, authority or instrumentality corporation) other (specify): Category of "Covered Security" (NSMIA): Offering to "Qualified Purchasers" [1933 Act* §18(b)(3)] Rule 506 Offering [1933 Act* § 4(2) - per §18(b)(4)(D)] Other qualifying offering (specify): * Securities Act of 1933, as amended The Securities Will Be Sold By: officers or directors of issuer salespersons employed by issuer officers or directors of an affiliated person underwriter, dealer or broker registered in New York For Theatrical Syndication Offerings, add the following information: Name of proposed production: Location of production: Proposed opening date: IPB099 - (rev. 5/12) American LegalNet, Inc. www.FormsWorkFlow.com B. INFORMATION ABOUT OFFERING Total Offering Amount (maximum) $____________ Type of Security Offered (brief description): Minimum Offering Amount $_______________ Enclosures (add additional sheets if necessary): Copy of Consent to Service of Process (U-2) (original to New York State Department of State, Albany NY) Offering Documents Confidential Attachment to Form 99 Further information as to issuer affiliated persons copy "as filed" with the S.E.C "as filed" copy will follow Form D: Theatrical Venture Amendment - Required Supplemental Information C. INFORMATION ABOUT ISSUER, PRINCIPALS AND CONTROLLING PERSONS · As to issuer: 1. Is issuer subject to or a respondent in any legal action for, any injunction, cease-and-desist order or order or stipulation to desist or refrain from any act or practice relating to the offering of securities in New York or any other jurisdiction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 2. (a) Has issuer ever been convicted of or pleaded guilty to any crime (i) involving any fraud, or (ii) relating to any financial transaction or handling of funds of another person, or (iii) pertaining to any dealings in any securities? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No (b) Is issuer now a defendant in any such criminal proceeding? . . . . . . . . . . . . . . . . . . . . . Yes No · As to each Principal*, each Controlling Person, and any Sponsoring Entity of issuer: 3. Is any one of the above subject to or a respondent in any legal action for, any injunction, cease-and-desist order or order or stipulation to desist or refrain from any act or practice relating to the offering of securities in New York or any other jurisdiction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No 4. (a) Has any one of the above ever been convicted of or pleaded guilty to any crime (i) involving any fraud, or (ii) relating to any financial transaction or handling of funds of another person, or (iii) pertaining to any dealings in any securities? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No (b) Is any one of the above now a defendant in any such criminal proceeding ? . . . . . . . . . 5. Yes No Has any of the above ever been suspended or expelled from membership in any securities or commodities exchange or association or had a securities or commodities license or registration denied, suspended or revoked? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No Has any of the above been a controlling person or sponsor with respect to any issuer which engaged in a distribution of securities or any public offering within the past three (3) years? . . . . . . . . . Yes No 6. If the answer to any of the above is "yes", give material facts on an attached sheet. * Capitalized terms are defined in Section E of Form 99. IPB099 - (rev. 5/12) 2 American LegalNet, Inc. www.FormsWorkFlow.com D. CERTIFICATION The undersigned affirms and certifies, to his or her knowledge and belief after due investigation and inquiry, and under penalty of perjury, that any and all information provided in this Form 99 is true and complete, and that there are no misrepresentations, omissions or untruths contained herein. The undersigned further understands and intends that the information supplied in this Form will be relied upon by the New York State Department of Law and that any false statement made herein is punishable as a Class A misdemeanor under New York Penal Law §175.30, §210.45, or both. Dated: ____________________________, 20 ____ Issuer (name of entity): _______________________ By: ______________________________________ Authorized Principal or Controlling Person Print Name: _______________________________ Title or Affiliation: __________________________ IPB099 - (rev. 5/12) 3 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL ATTACHMENT TO FORM 99 (Social Security numbers and residential information will be held strictly confidential) Issuer Name: ______________________________________________________________ Form 99 dated: _____________________, 20 ___ ACCESS TO THE FOLLOWING INFORMATION WILL BE WITHHELD PURSUANT TO NEW YORK PUBLIC OFFICERS LAW ("FOIL") §89(2)(b): Identity of Principals (i) of issuer, (ii) of Controlling Person(s)* and (iii) of Sponsoring Entity: Name ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ Date of Birth ______________________ _____________________
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