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Application For Approval Of Corporate Reorganization 4 - Ohio

Application For Approval Of Corporate Reorganization Form. This is a Ohio form and can be used in Securities Blue Sky Secretary Of State .
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77 South High Street, 22nd Floor Columbus, Ohio 43215-6131 Telephone: (614) 644-7381 File Number Form 4 Application for Approval of Corporate Reorganization Pursuant to R.C. 1707.04 For Division Use Only. Do Not Fill In. Fee ($100) Received Hearing Expenses ($ ) Received Date Checked By Note: Use this form to apply for a fairness hearing to be conducted by the Division of Securities regarding the issuance of securities as part of a plan of reorganization, recapitalization, or refinancing of a corporation. The non-refundable filing fee is $100, plus hearing expenses, as determined by the Division, not to exceed $1,000. Submit to the Ohio Division of Securities, 77 South High Street, 22nd Floor, Columbus, Ohio 43215-6131, prior to the commencement of any plan of reorganization, the following: (1) the completed Form 4, (2) the filing fee ($100) by check or money order payable to the "Ohio Division of Securities", and (3) all required exhibits. To the Division of Securities: The undersigned hereby makes application for a hearing before the Division of Securities to approve the terms and conditions of the issuance of securities of (Name of Corporation) under the terms and provisions of a plan of (check one) reorganization, recapitalization, or refinancing of such corporation under the provisions of Section 1707.04 of the Ohio Revised Code. The facts herein stated are true and constitute a fair and complete statement of all material facts relating to the plan of reorganization, recapitalization, or refinancing, and the issuance of securities thereunder for which this application is made. 1. Full Legal Name of Issuing Corporation: (Payer's Federal Tax Identification Number) 2. Issuer's principle place of business: (Number and Street) (Address Line 2) (City, State, Zip code) (Website, if applicable) (Phone No.) 3. Date and state of Issuer's incorporation: (Month, Day and Year) (State) American LegalNet, Inc. www.FormsWorkFlow.com 4. Correspondence regarding this application should be sent to: (Name) (Title) (Entity) (Phone No.) (Number and Street) (Address Line 2) (City, State, Zip code) (E-mail) 5. Briefly describe the Issuer's business. (If more space is needed, submit additional document(s) and number as Exhibit 6) 6. Attached hereto, and made a part hereof, are the following exhibits: (Furnish Exhibits (B) through (N) only to the extent that information required does not appear in Exhibit (A). A. B. A copy of the plan of reorganization, recapitalization, or refinancing. A list of the names and addresses of all directors and officers and of members of any protective committees or other persons active in the reorganization. A statement of the number of shares of each class of stock to be reorganized held by each of the persons mentioned in Exhibit (B), together with the compensation received or to be received by each such person in connection with the reorganization and, in the case of officers and directors, the compensation to be received from and the time to be devoted to the corporation after reorganization. A statement of each class of securities outstanding, and of the new securities to be outstanding, after the reorganization. Identify each person who will acquire or hold five percent (5%) or more of the voting stock of the corporation after reorganization. A copy of the Articles of Incorporation of the corporation, and all amendments thereto and proposed amendments. A copy of the Regulations or By-Laws of the corporation, and all amendments thereto and proposed amendments. Copies of all trust indentures, agreements, or other instruments under which any new securities of the corporation are to be issued. If any new securities are to be sold, copies of all contracts entered into for the sale of such securities. Include any documents related to the method to be employed by the issuer for distributing securities issued by it, such as selected dealer agreements and form of subscription agreements, and a copy of any SEC registration statements. Copies of all written materials to be used in connection with the proposed transaction, including, but not limited to, advertisements, prospectuses, sales literature, etc. American LegalNet, Inc. www.FormsWorkFlow.com C. D. E. F. G H. I. J. (a) An itemized statement showing all expenses of the proposed transaction. (Where this is not known, estimates should be provided and indicated as such.) If any new securities are to be sold, an itemized statement showing all commissions, remunerations, charges and other expenses which will be paid in connection with such sale. (b) K. A list of all security holders and creditors to whom it is proposed to issue new securities, showing the class of securities and the amounts currently held and to be held by each or, in the case of creditors, the amounts due before and after the reorganization. A certified balance sheet showing the true financial condition of the issuer as of a date within three months of the date of filing this application, and a pro forma balance sheet showing the intended financial condition after the proposed transaction has been completed. A profit and loss statement for each of the preceding three years, and for the one year ending not more than three months prior to the filing of this application. An opinion of counsel as to the validity of the new securities to be issued. SIGNATURE Issuer: L. M. N. By: VERIFICATION (Verification by One Person is Sufficient) County of State of The undersigned, , being first duly sworn, deposes and says: That he or she has executed the foregoing for, and on behalf of, the applicant named therein; that he or she is the of such applicant and is fully authorized to execute and file such application on its behalf; that he or she is familiar with such application and the facts underlying such application; and that to the best of his or her knowledge, information and belief, the statements made in such application are true and the documents submitted herewith are true copies of the original thereof. Signature of Person Sworn Office Held Month, Day and Year Subscribed and sworn to before me Signature of Notary Public An Equal Opportunity Employer and Service Provider COM 4653 (Revised 12/2013) FOR TTD/TYY: 1-800-750-0750 American LegalNet, Inc. www.FormsWorkFlow.com
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