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Notification Of Claim Exemption - Washington
| Notification Of Claim Exemption Form. This is a Washington form and can be used in Securities Blue Sky Secretary Of State . |
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State of Washington Department of Financial Institutions Securities Division PO Box 9033 Olympia, WA 98507-9033 (360) 902-8760 1. Name of Issuer NOTIFICATION OF CLAIM EXEMPTION PURSUANT TO RCW 21.20.320(9), WAC 460-44A-504, AND SECURITIES AND EXCHANGE COMMISSION RULE 147 Phone Number 2. Form of Organization (check One) Corporation Unincorporated Association Limited Partnership Other Specify Address of Issuer 4. Name (in full), address and telephone NOTE: If the controlling person, promoter, or If corporation: chief executive officer general partner is not a natural person, if unincorporated association: promoter or provide similar information for a natura controlling person person having primary responsibility to If partnership: general partner the affairs of the issuer. If other: controlling person Name (Notarized signature required on reverse side of this form.) Position 3. Type of Business (check one) Manufacturing Service Extractive Real Estate Other (specify) Address Phone Number 5. Issuer 's state of incorporation or or jurisdiction of organization. Date of incorporation or organization 6. Title of class of securities to be sold in this offering 7. Total number of shares or units of securities to be sold in this offering. 8. Aggregate dollar amount of the offering. 9. Price per share or unit of securities to be sold. 10. Total number of purchasers other than accredited investors to whom securities are to be sold. 11. Past securities sales. List all securities sole by the issuer within the 12 months preceding the filing of this form. (Continue of reverse side.) Date of Sale Description of Security Amount Basis on which securities were sold, i.e., Exemption or Registration under Federal Securities Act of 1933 and Washington State Securities Act. 12. FILING FEE ENCLOSED. Fifty Dollars ($50.00) to accompany Notification of Claim of Exemption SC-610-009 (R/8/93)M Pag 1eof 2 American LegalNet, Inc. www.FormsWorkFlow.com By filing this Notification of Claim of Exemption in the state of Washington pursuant to WAC 460-44A-503(1)(a)(i)(D), the issuer of these securities hereby represents that:: (1) The issuer shall at the time of any offers and sales be a person resident and doing business within Washington, and that all offers to sell, offers for sale, and sales shall be made within this state; (2) Offers, offers to sell, offers for sale and sales of these securities shall be made only to persons within the state of Washington; and resident (3)The issuer has reviewed and shall meet the requirements for exemption from registration pursuant to Securities and Exchange Commission Rule 147, and shall disclose in writing the limitations on resales and implement precautions against interstate offers and sales as provided in the rule, including placing a legend on the certificate or other document evidencing the security stating that the securities have not been registered under the Act and setting forth the limitations on resale as stated below, and obtaining a written representation from each purchaser as to his residence. THESE SECURITIES HAVE NOT BEEN REGISTERED WITH THE SECURITIES AND EXCHANGE COMMISSION UNDER THE SECURITIES ACT OF 1933 (" THE ACT" BUT ARE BEING SOLD IN RELIANCE UPON THE ), EXEMPTION FROM REGISTRATION PROVIDED IN SECTION 3(A)(11) OF THE ACT AND RULE 147 PROMULGATED THEREUNDER. ACCORDINGLY, RESALES AND TRANSFERS OF THESE SECURITIES ARE STRICTLY LIMITED TO RESIDENTS OF THE STATE OF WASHINGTON FOR A PERIOD OF AT LEAST NINE MONTHS FROM THE DATE OF THE LAST SALE OF THE OFFERING BY THE ISSUER OF THE SECURITIES IN WHICH THE SECURITIES ARE DEEMED TO BE A PART. DO NOT SEND OFFERING MATERIALS OR PROSPECTUS UNLESS SPECIFICALLY REQUESTED BY THE SECURITIES DIVISION The undersigned officer or person acting in a similar capacity has duly caused this notification to be filed on behalf of the issuer and has read this notification and knows the contents hereof and the statements therein to be true. ISSUER _______________________________ DATE _____________________________ SIGNATURE ______________________________________________________________ _________________________________________________________________________ Type Name and Title Subscribed and sworn to before me this _____________ day of ____________ 20 _________ S E A L _____________________________________________ _____________________________________________ Residing at __________________________________ ATTENTION: Intentional misstatements or omissions of facts constitute criminal violations. (See RCW 21.20.400) SC-610-009 (R/8/93)M Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com
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