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Report Of Sale Of Securities 3Q - Ohio
| Report Of 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-Q REPORT OF SALE OF SECURITIES 1707.03(Q) Claimant Must Not fill In. Checked Division Record -- Date By Notation Fee ($100/$50 Received Prior filings checked Examined as to form Amendment Requested Accepted for Filing Record Made Examination Requested Exemption 3-Q (Claimant Must Not Fill In. (File) (Date) (Amount) (Description) (Price) Note: Use this form to claim a section 1707.03(Q) exemption for securities s old in Ohio within 60 days of the filing of this form and not previously reported. Only those issuers relying on Section 4(2) of th e Securities Act of 1933 are eligible to use this exemption. The non-refundable filing fee is $100 for the first filing and $50 for a ny subsequent related Form 3-Q filing made during the same calendar year. Submit to the Ohio Division of Securities, 77 South High Street, Columbus, Ohi o 43215-6131 the following: (1) the completed Form 3-Q, (2) the filing fee by check or money order payable to the Ohio Division of Securities, and (3) exhibits or schedules, if any.1. Issuers full name Payers Federal Tax Identification Number2. Issuers Address (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. A section 1707.03(Q) claim of exemption is being made for the followin g securities sold in Ohio within 60 days of the filing of this form and not previously reported (use additional sheet, if nec essary): Type of Date of Number of Price Number of Securities Sold Sale Units Sold per Unit Purchasers American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2 Note: O.A.C. rule 1301:6-3-03(B)(5) deems a sale to have occurred on the l ater of: (a) the date that a subscription agreement or its equivalent, signed by the purchaser, is received by the issuer or the de aler, or the purchaser transfers or loses control of the purchase funds, whichever is earlier; or (b) the first date of disburs ement of any proceeds of the sale of the securities which have been deposited directly into an escrow account. 6. Confirm that the basis in law for this claim of exemption from Section 5 of the Securities Act of 1933 is pursuant to Section 4(2) of that Act. Note that Rules 504, 505 and 506 cannot be used as a basis for claiming the exemption pursuant to Section 1707.03(Q). 7. List the total number of persons who have purchased this offering to dat e, both in and outside of Ohio, including persons claimed on all previous Form 3-Qs filed in connection with this offering. 8. (a) 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 claimed on the Form 3-Q (if none, please state None). Use additional sheet if necessary. Name and address of person Amount of Percentage of receiving commission, etc. commission, etc. the Initial Offering Price (b Were above commissions, discounts, or other remuneration paid or given o nly to dealers or salesmen licensed under ) Chapter 1707 of the Revised Code? q YES q NO 9. Was an offering circular used in connection with the sales reported on t his Form 3-Q?q YES q NO If yes, q Copy attached orq Previously submitted 10 Has this offering been terminated?q YES q NO . If yes, date of termination 11 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.) SIGNATURE The undersigned represents that the foregoing information is true as of the date hereof and agrees that this report shall beconsidered a written statement used for the purpose of selling securitie s in Ohio within the meaning of Section 1707.44(B) ofthe Ohio Revised Code. The individual signing this report on behalf of the issuer further represents that he/she is dulyauthorized by the issuer to execute and file this report. Issuer or Dealer (Full Name) By (Signature) (Date) (Name) (Official Capacity) The Division suggests Form 3-Q be sent certified mail for verification o f receipt, or send a copy of this form together with aself-addressed, stamped envelope. Com 4596 (Rev. 2/05) American LegalNet, Inc. www.USCourtForms.com
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