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Report Of Proposed Sale Of Securities 3-W - Ohio
| Report Of Proposed Sale Of Securities 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 File Number (614) 644-7381 Division of Securities 77 South High Street, Columbus, Ohio 43215-6131 Form 3-W REPORT OF PROPOSED SALE OF SECURITIES 1707.03(W) Claimant Must Not fill In. Checked Division Record -- Date By Notation Fee ($100 Received Prior registrations checked Examined as to form Amendment requested Record Made Examination Requested Exemption 3-W (Claimant Must Not Fill In. (File) (Date) (Amount) (Description) (Price) Instructions: This form to be used only for any offer or sales to be made in reliance on the exemptions provided by Rule 505 of Regulation D madepursuant to the Securities Act of 1933. This form and the one hundred d ollar filing fee should be submitted to the Ohio Division ofSecurities, 77 South High Street, Columbus, Ohio 43215-6131. Five days after receipt by the Division, offers may begin.1. Issuers full name Payers Federal Tax Identification Number2. Issuers Address (Street) (City, State, Zip) (Phone No.)3. State 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(W): Type of Securities Price Per Unit Number of Units Sold Total Offering6. Briefly describe the issuers business. Com 4596 (Rev. 2/05) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 27. 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 8. Does the issuer know or in the exercise of reasonable care could know th at any of the following apply to any person described in Rule 262(a) to (c) of Regulation A under the Securities Act of 1933: (i) The person has filed an application for registration or qualifica tion that is the subject of an effective order entered against the issuer, its officers, directors, general partners, controlli ng persons or affiliates thereof, pursuant to the law of any state within five years before the filing of notice required under S ection 1707.03(W)(3) denying effectiveness to, or suspending or revoking the effectiveness of, the registration statement. q YES q NO (ii) The person has been convicted of any offense in connection with the offer, sale, or purchase of any security or franchise, or any felony involving fraud or deceit, including but not li mited to forgery, embezzlement, fraud, theft, or conspiracy to defraud. q YES q NO (iii) The person is subject to an effective administrative order or j udgement entered by a state securities administrator within five years before the filing of a notice required under Section 1 707.03(W)(3), that prohibits, denies, or revokes the use of any exemption from securities registration, that prohibits the tr ansaction of business by the person as a broker or dealer, or that is based on fraud, deceit, an untrue statement of a mate rial fact or an omission to state a material fact. q YES q NO (iv) The person is subject to any order, judgment or decree of any co urt entered within five years before the filing of a notice required under Section 1707.03(W)(3), temporarily, preliminar ily, or permanently restraining or enjoining the person from engaging in or continuing any conduct or practice in connect ion with the offer, sale, or purchase of any security, or making of any false filing with any state. q YES q NO If any of the above questions were answered yes, explain: 9. Incorporated issuers not domiciled in this state or unincorporated issue rs having a situs of its principal place of business outside this state must file a Form 11 or Form U-2. (See section 1707. 11, R.C.) 10. Will an offering circular be used in connection with this offering? q YES q NO If yes, attach a copy. 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) of the OhioRevised Code. The individual signing this report on behalf of the issue r further represents that he/she is duly authorized bythe issuer to execute and file this report. Issuer (Full Name) By (Signature) (Date) (Please Print or type Name) (Official Capacity) The Division suggests Form 3-W 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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