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Filing Of Information Pertaining To A Control Bid 041 - Ohio
| Filing Of Information Pertaining To A Control Bid Form. This is a Ohio form and can be used in Securities Blue Sky Secretary Of State . |
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STATE OF OHIO Telephone: Department of Commerce (614) 644-7381 Division of Securities File No. 77 South High Street, 22nd Floor, Columbus, Ohio 43215 FORM 041 FILING OF INFORMATION PERTAINING TO A CONTROL BID Pursuant to Section 1707.041 of the Revised Code of Ohio Division Record Date Checked By Notation Do Not Fill In Received by Division Record Made Other Filings under this Section by this Offeror: File No. File No. INSTRUCTIONS: Responses may be made either directly on this form, by reference to doc uments and exhibits filed with this form, or a combination of both. If the space provided on this form is inadequate fo r full response, or if response will be made by referring to a document or exhibit filed with this form, attach an exhibit numbered to correspond to the number of the item being answered, and note the reference to the exhibit in the space provided. If the exhibit consists of more than one page, indicate the relevant page number(s). If there is more than one Offeror, each Offeror should fill out Part Two of this form. Please DO NOT LEAVE ANY ITEM BLANK. If an item will not be answered, note either that the item is not applicable (NA), or, if reasonable investigation of information actually or publicly availab le to the Offeror has not revealed the answer, that the answer is unknown ( UK). PART ONE: SUBJECT COMPANY EXHIBIT REFERENCES 1. State the name and principal place of business of the Subject Company, 1707.01(Y)(1) including the street address, telephone number and facsimile number. State the name, address, telephone number and facsimile number of the Subject Companys legal counsel: 2. State the location of the principal executive office of the Subject Com- 1707.01(Y)(1) pany, including the address, telephone number and facsimile number: 3. State the form of organization of the Subject Company, the date on which 1707.041(A)(2)(h) it was formed, and jurisdiction in which it was organized: 1707.23(A) 4. Indicate if the Subject Company is any of the following: A banking corporation subject to regulation by the Ohio Division of Financial Institutions 1707.041(C) YES NO 1707.01(M) A savings and loan association subject to regulation by the Ohio Divisio n 1707.01(O) of Financial Institutions. YES NO A public utility corporation subject to regulation by the Ohio Public Ut ili- ties Commission YES NO COM 4522 (1-99) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 EXHIBIT REFERENCES 5. Identify the current executive officers and directors of the Subject Com pany, including 1707.01(Y) the title, city and state of residence and beneficial share ownership of each person: 1707.041(A)(2)(h) 1707.23(A) 6. Describe each of the Subject Companys outstanding securities (incl ude all kinds and 1707.01(Y) classes of stocks, bonds, debentures, promissory notes, warrants, option s, or other securi- 1707.041(A)(2)(h) ties), authorized by the Articles of Incorporation or other document of the Subject Com- 1707.23(A) pany, and the terms of each security. For EACH security, state the numb er or amount authorized, the number or amount outstanding, the market on which it is traded, its trading symbol, and the name and address of its transfer agent: 7. The Subject Company has record and beneficial holders, respectively, of 1707.01(Y)(1) (Number) (Number) 1707.01(Z) its equity securities. , or %, of the record and beneficial holder, are 1707.01(BB) (Number) 1707.23(A) residents of Ohio and their ownership constitutes % of the record and % of the beneficial holders of such equity securities, respectively. 8. State the approximate fair market value, in dollars, of the assets loca ted in Ohio which 1707.01(Y)(1) the Subject Company owns or controls: 1707.23(A) 9. Describe the location and general character of the principal physica l properties of the 1707.041(A)(2)(d) Subject Company and its subsidiaries: 1707.041(A)(2)(h) 1707.23(A)10. State the locations in Ohio where the Subject Company has employees, an d the approxi- mate number of employees in each location: 1707.041(A)(2)(d) 1707.23(A) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3PART TWO: OFFEROR EXHIBIT REFERENCES11. State the name and principal place of business of the Offeror, including its street address 1707.01(W) and telephone number: 1707.041(A)(2)(b) 1707.041(A)(2)(g)12. State the form of organization of the Offeror (e.g., partnership, corpo ration, association), 1707.01(W) the data on which it was formed, and jurisdiction in which it was organi zed (including 1707.041(A)(2)(g) country and state, province, or other political subdivision): 13. Indicate if the Offeror is any of the following: 1707.041(C) A banking corporation subject to regulation by the Ohio Division of Fina ncial 1707.01(M) Institutions 1707.01(O) YES NO A savings and loan association subject to regulation by the Ohio Divisi on of Financial Institutions YES NO A public utility corporation subject to regulation by the Ohio Public Utilities Commis- sion YES NO 14. Identify the executive officers and directors (or partners, if the Offe ror is a partnership, or 1707.01(W) other similar persons if the Offeror is in another form or entity) of t he Offeror for the past 1707.041(A)(2)(g) three years, including the title, term of office, and city and state o f residence of each person (in an exhibit, supply a biography for all persons identified in this item): 15. Describe each of the Offerors outstanding securities (include all kind s and classes of 1707.01(W) stocks, bonds, debentures, promissory notes, warrants, options, or other securities), au- 1707.041(A)(2)(c) thorized by the Articles of Incorporation or other document of the Offer or, and the terms 1707.041(A)(2)(g) of each security. For EACH security, state the number or amount authoriz ed, the number or amount outstanding, the market on which it is traded, its trading s ymbol, and the name and address of its transfer agent: 16. List the subsidiaries and affiliates of the Offeror, including its name, form of organization, the 1707.01(W) jurisdiction in which it was organized and, if different, the jurisdicti on of its principal execu- 1707.041(A)(2)(g) tive offices and the owner and percentage of ownership of each subsidiar y and affiliate: 1707.041(A)(2)(h)17. Describe the location and general character of the principal physical pr operties of the 1707.01(W) Offeror, including those of the related entities described in item No. 1 6: 1
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