Pennsylvania > Department Of State > Blue Sky > Securities
Supplement To Form U-1 R - Pennsylvania
| Supplement To Form U-1 Form. This is a Pennsylvania form and can be used in Securities Blue Sky Department Of State . |
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PSC FORM R SUPPLEMENT TO FORM U-1 COMMONWEALTH OF PENNSYLVANIA PENNSYLVANIA SECURITIES COMMISSION APPLICATION TO REGISTER SECURITIES UNDER THE PENNSYLVANIA SECURITIES ACT OF 1972 (CHECK ONLY ONE) SECTION 205 - REGISTRATION BY COORDINATION [ ] SECTION 206 - REGISTRATION BY QUALIFICATION [ ] 1. Legal Status of the Issuer (A) Exact name of Issuer: (B) State and Date of incorporation or formation: State Date 2. Addresses (A) Address of principal office of Issuer: Number and Street City State Zip Code Telephone No. (B) Address of principal office of Issuer in Pennsylvania (if other t han listed in (A)): Number and Street City State Zip Code Telephone No. (C) Name and address of person to whom correspondence regarding this f iling should be sent: Name Title Number and Street City State Zip Code Telephone No. (D) Name and address of counsel to Issuer (if other than listed in ( C)): Name Title Number and Street City State Zip Code Telephone No. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 23. Information about the Executive Officers of the Issuer (A) State the names and addresses of persons holding any of the following po sitions with the Issuer: (i) General partner (ii) Promoter (as defined in Section 102(o) of the Act) (iii) Manager (if a limited liability company) (iv) President (v) Chief executive officer (vi) Chief operating officer (vii) Chief financial officer (viii) Director of the Issuer who owns 5% or more of any class of voting equity securities of the Issuer (exclusive of any beneficial interest in a vot ing shareholder which is an institutional investor as defined in Section 102(k) of the Act and Regulation 102.111). (B) Indicate if any person described in (A) currently is registered as an agent under Section 301 of the Act or as a principal of a broker-dealer registered under Sec tion 301 of the Act. NO YES If YES, provide the individuals name, employer and Central Registration Depository number. 4. Prior Disciplinary History (A) Indicate if any person described in Item 3(A) has been convicted of an y crime or made the subject of any sanction described in Section 305(a)(ii)-(ix) o f the Act. NO YES If YES, describe fully. (B) Indicate if any person described in Item 3(A) has been the subject of a Commission order issued under Section 512 (Statutory Bars) or Section 513 (Rescission Offer) of the Act or an order of a court of competent jurisdiction under Section 509(c) of the Act (Civil Contempt). NO YES If YES, describe fully. 5. Previous Sales of Securities in Pennsylvania (A) By the Issuer Describe all sales of securities made in Pennsylvania during the past tw o years that directly or indirectly benefitted the Issuer. Include securities issued in exchange for property, services, or other securities and new securities resulting from the modification of o utstanding securities. In each case, state: (i) The date of sale and description of the securities sold; (ii) Underwriting or selling fees or commissions paid and to whom paid; (iii) Section of the Act or regulation relied upon for the offer and sale of s ecurities. NO YES American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3 (B) By a person related to the Issuer Within the period of two years prior to the date of this Form, did any p erson described in Item 3(A) hold a position as a general partner, promoter (as defined in Se ction 102(o) of the Act), manager (if a limited liability company), president, chief executive o fficer, chief operating officer, chief financial officer or a director with a 5% or more ownership of any class of voting equity securities of the issuer (exclusive of any beneficial interest in a vot ing shareholder which is an institutional investor as defined in Section 102(k) of the Act and Reg ulation 102.111) with another person, not the Issuer, at the time when that person sold securities in Pennsylvania for which a filing with the Commission was required? NO YES If YES, provide the following information: (i) Name of the other person that sold the securities; (ii) The position held with the other person; (iii) Section of the Act or regulation relied upon for the offer and sale of s ecurities; If (iv) the proceeds from the sale were paid directly or indirectly to, or used directly or indirectly for, the benefit of the Issuer, please describe in detail. 6. If an independent accountant has been engaged as the principal accountan t to audit the most recent financial statement of Issuer or, where Issuer is a partnership, the general partner(s) of Issuer, and such accountant was not the principal accountant for the pre vious fiscal years certified financial statements, state the date upon which the successor accountant was engaged and whether preceding such engagement there were any disagreements with the predecessor accountant on any matter of accounting principles or practices, financia l statement disclosure, or auditing procedure, which disagreements, if not resolved to the satisfac tion of the predecessor accountant would have caused him to make reference in connection with hi s opinion to the subject matter of the disagreement. In response to Items 7 - 16, please provide the following information or refer to the page of the prospectus where complete information concerning each item may be fo und. 7. (A) If any non-cash consideration is to be paid for the securities off ered, describe fully and indicate the method of valuation. (B) State whether any adverse order, judgement or decree has been ent ered, or any proceeding is pending, before the United States Securities and Exchange Commission or any court in connection with the securities included within this registration stateme nt, or other securities of the same kind or class. (C) State the names of all underwriters and broker-dealers proposing t o sell or offer these securities for sale in Pennsylvania. (If all such names are not known a t the time of filing this Form, a supplemental list may be filed prior to or after effectiveness; provided that no person may participate in this offering as a underwriter or dealer in Pennsylvania until notice of such fact has been filed with the Commission.) (D) With respect to any person receiving compensation who is not a bro ker-dealer registered under Section 301 of the Act, explain why the person is not a promoter a s that term is defined in Section 102(o) of the Act. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>
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