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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 7/27/2015
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File # NY FORM 99 Telephone Number ( ) - (Number and Street) (City or Town) (State & ZIP) 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): Offering to "Qualified Purchasers" [1933 Act §18(b)(3)] Rule 506 Offering [1933 Act* § 4(2) - per §18(b)(4)(D)] Regulation A, Tier 2 Offering [1933 Act* §3(b)(2) - per §§ 18(b)(3) & 18(b)(4)(D)(ii)] Other qualifying offering (specify): * Securities Act of 1933, as amended officers or directors of issuer officers or directors of an affiliated person salespersons employed by issuer underwriter, dealer or broker registered in New York Name of proposed production: Location of production: Proposed opening date: ) IPB/REF099 - (rev. 7/2015 American LegalNet, Inc. www.FormsWorkFlow.com B. Total Offering Amount (maximum) $ INFORMATION ABOUT OFFERING Minimum Offering Amount $_ Type of Security Offered (brief description): 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 Form D: copy "as filed" with the S.E.C "as filed" copy will follow Form 1-A 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 No (iii) pertaining to any dealings in any securities? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes (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 ? . . . . . . . . . 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 5. 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. IPB/REF099 - (rev. 7/201 5) 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: IPB/REF099 - (rev. 7/201 5) 3 American LegalNet, Inc. www.FormsWorkFlow.com ATTACHMENT TO FORM 99 Issuer Name: ______________________________________________________________ Form 99 dated: _____________________, 20 ___ Identity of Principals (i) of issuer, (ii) of Controlling Person(s)* and (iii) of Sponsoring Entity: Person/Company Name _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ Date of Birth/Organization _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ Social Security/Tax ID Number ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ Amendments: Additions or Deletions of Principals with Effective Date of Change Person/Company Name ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ Date of Birth/Organization Social Security/Tax ID Number _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ Effective Date ____________ ____________ ____________ ____________ ____________ ____________ *Capitalized terms a
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