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Notice Of Proposed Public Offering Solely To Accredited Investors 3-Y - Ohio
| Notice Of Proposed Public Offering Solely To Accredited Investors Form. This is a Ohio form and can be used in Securities Blue Sky Secretary Of State . |
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STATE OF OHIO File Number Telephone Department of Commerce (614) 644-7381 Division of Securities 77 South High Street, Columbus, Ohio 43215-6131 Form 3-Y Notice of Proposed Public Offering Solely to Accredited Investors Model Accredited Investors Exemptions 1707.03(Y) Claimant Must Not fill In. Checked Division Record -- Date By Notation Fee ($100) Received Prior filings checked Examined as to form Amendment requested Record Made Examination Requested Exemption 3-Y (Claimant Must Not Fill In. (File) (Date) (Amount) (Description) (Price) Instructions: This form to be used only for any offer and sale of securities made sole ly to accredited investors, as defined in Rule 501 of regulation Dunder the Securities Act of 1933, made in reliance on the exemption unde r R.C. 1707.03(Y). This form, with a $100 filing fee and the nd required exhibits, must be submitted to the Ohio Division of Securities, 77 S. High Street, 22 Floor, Columbus, OH 43215-6131 withinfifteen days of the first use of a general announcement of the offering. Note: This form may not be filed in connection with offeringsexempt under R.C. 1707.03(Q), (W) or (X). 1. Issuers full name Payers Federal Tax Identification Number2. Issuers Address (Street) (City, State, Zip) (Phone No.)3. State of incorporation/formation Date of incorporation/formation Type of Entity (Corporation, Partnership, etc.) 4. Correspondence regarding this report should be sent to: (Name) (Street) (City, State, Zip Code) (Phone No.)5. Securities to be offered in Ohio under Section 1707.03(Y): Type of Securities Price Per Unit Number of Units Sold Total OfferingCom 4508 (Rev. 5/05) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 26. Briefly describe the issuers business and attach a copy of the gener al announcement of the proposed offering. 7. List any commissions, discounts, or other remuneration paid or to be pai d or given to any person, directly or indirectly, for sales in Ohio of the securities to be offered under this exemption. Name and address of person Amount of Percentage of Ohio Dealer License # receiving commissions, etc. commission, etc. Initial Offering Price or CRD # 8. Is the issuer in the development stage?q YES q NO (i) Does the issuer have a business plan?q YES q NO (Note: The exemption is not available to an issuer in the development stage that does not have a business plan.) (ii) Is the business plan to engage in a merger or acquisition with a n unidentified company or companies, or other entities or persons? q YES q NO (The exemption is not available if the business plan is to engage in a merger or acquisition with an unidentified company or companies, or other entities or persons.) 9. Does the issuer know, or in the exercise of reasonable care based on rea sonable investigation could have known, that any of the following apply to any person described in R.C. 1707.03(Y)(4) : (i) Within the past five years, the person has filed a registration s tatement that is the subject of a currently effective registration stop order entered by any state securities administrator or the Securities and Exchange Commission. q YES q NO (ii) Within the past five years, the person has been convicted of any criminal offense in connection with an offer, purchase or sale of any security, or involving fraud or deceit. q YES q NO (iii) The person is currently subject to any state or federal adminis trative enforcement order or judgment, entered into within the past five years, finding fraud or deceit in connection with t he purchase or sale of any security. q YES q NO (iv) The person is currently subject to an order, judgment or decree of any court of competent jurisdiction, entered into with the past five years, that temporarily, preliminarily or permanently restrains or enjoins the person from engaging in or continuing to engage in any conduct or practice involving fraud or decei t in connection with the purchase or sale of any security. q YES q NO If any of the above questions were answered yes, provide an explanation and details: The exemption under R.C. 1707.03(Y) is not available to any issuer if any of the above questions were answered yes, unlessthe issuer can affirmatively respond to either of the following: (v) The person subject to the disqualification is licensed or registe red to conduct securities business in the state in which the order, judgment or decree was entered against the party. q YES q NO (vi) Before the first offer is made under R.C. 1707.03(Y), the stat e securities administrator, court or regulatory authority that entered the order, judgment or decree waives the disqualification. q YES q NO American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3Provide a summary and explanation of the response: 10. Incorporated issuers not domiciled in this State or licensed under R.C. 1703.03 or unincorporated issuers having a situs of its principal place of business outside this State must file a Form 1 1 or Form U-2 (See R.C. 1707.11) 11. Will an offering circular, private placement memorandum or other written materials be used in connection with this offering? q YES q NO If yes, attach copies of all written materials. SIGNATURE The issuer represents that the foregoing information is true as of the d ate hereof and agrees that this report shall be considereda written statement used for the purpose of selling securities in Ohio w ithin the meaning of Section 1707.44(B). The individual signing this report on behalf of the issuer further represent s that he/she is duly authorized by the issuer to executeand file this report. Issuer (Full Name) By (Signature) (Date) (Please Print or type Name) (Official Capacity) The Division suggests Form 3-Y be sent certified mail for verification o f receipt, or send a copy of this form together with aself-addressed, stamped envelope. American LegalNet, Inc. www.USCourtForms.com
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