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Notice Under Section 203(P) Of The Pennsylvania Securities Act Of 1972 203P - Pennsylvania
| Notice Under Section 203(P) Of The Pennsylvania Securities Act Of 1972 Form. This is a Pennsylvania form and can be used in Securities Blue Sky Department Of State . |
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EFFECTIVE: 10/12/74 FORM 203-PREVISED: 12/23/04 COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA SECURITIES COMMISSION NOTICE UNDER SECTION 203(p) OF THE PENNSYLVANIA SECURITIES ACT OF 1972 1. Exact Name of Issuer: 2. (A) Address of principal office of Issuer: Number and Street City State Zip Code Telephone No. (B) Address of Issuers primary place of business in Pennsylvania (if other than listed in (A)): Number and Street City State Zip Code Telephone No. 3. (A) Name and address of person to whom correspondence regarding this filing should be sent: Name Title Number and Street City State Zip Code Telephone No. (B) Name and address of counsel to Issuer (if other than listed in (A)): Name Title Number and Street City State Zip Code Telephone No. (C) Name and address of accountants of Issuer: Name Title Number and Street City State Zip Code Telephone No. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 24. (A) Legal Form of Issuer (corporation, partnership, association, etc.): (B) State and Date of Incorporation: State Date (C) Name of any Predecessor of Issuer: (D) Purpose for which Issuer was formed and nature of its activities: 5. (A) Describe type and amount of securities proposed to be sold, price per unit and anticipated total net proceeds to the Issuer. List separately the amoun ts proposed to be paid for the costs of the offering and any underwriting fe e or sales commissions. Identify all persons who will receive any such fee or co mmission and the basis on which it will be paid. Identify also any person who will receive any monies for assistance rendered in developing the offering plan and the amount of compensation paid, or to be paid, to each person. (B) Describe any subordination, sinking fund, call and all other material pr ovisions of the securities being offered and any assets in which a mor tgage or security interest is being created for the benefit of the security holders. (C) Attach a copy of the security being sold. (D) Attach a copy of an appraisal or other document indicating the fair mark et value of the collateral. (E) Describe the terms of any escrow being created to satisfy the requirem ents of Section 203(p)(5). 6. Describe in detail the intended use of proceeds from the offering, stati ng the amounts to be used for each purpose and order of priority of uses indicated. 7. State the Section of the Internal Revenue Code under which Issuer claims tax exempt status, if any. Has any such tax exemption ever been challenged? YES NO If yes, describe fully all surrounding facts and circumstances and state the result of such challenge. 8. Has the Issuer, within the previous two years, sold securities in Pennsy lvania? YES NO If YES, describe the circumstances under which sales were made, includin g: (i) offering prices; (ii) the dates, class and amounts of securities sold; (iii) the exemption or other provision of the Act or regulations of the Commission relied upon in eac h instance. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 39. Affirmation. By executing this Form on behalf of the issuer, the signatory affirms th at: A. The undersigned is familiar with the provisions of Section 203( p) and all regulations adopted thereunder. B. The statements made in this Notice, including all attachments her eto, taken individually or collectively, are not incomplete in any material respect or false or misleading with respect to any material fact. IN WITNESS WHEREOF, this Notice has even duly executed (Insert Date) (NAME OF ISSUER) BY: (TITLE) American LegalNet, Inc. www.USCourtForms.com
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