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ACE-NET Report Form FIS-0557 - Michigan
| ACE-NET Report Form Form. This is a Michigan form and can be used in Securities Filing Securities Blue Sky Secretary Of State . |
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FIS 0557 (5/04) Office of Financial and Insurance Services This form is issued under Act 265, PA 1964, as amended. This form must be completed pursuant to the ACE-NET exemption under Section 402(b)(20) of the Act. Failure to file will disqualify the issuer from utilizing this exemption. MICHIGAN DEPARTMENT OF LABOR & ECONOMIC GROWTH OFFICE OF FINANCIAL AND INSURANCE SERVICES ACE-NET REPORT FORM INSTRUCTIONS: This form must be filed to comply with the ACE-NET exemption from registration pursuant to Section 402(b)(20) of the Michigan Uniform Securities Act. The Report must be filed within 15 days of the first Michigan sale by the Issuer and must be signed by an authorized agent or representative. Issuer Address Description of Securities Date that offering was initiated in Michigan Signature of Authorized Agent or Representative Title Date Signed RETURN TO: Michigan Department of Labor & Economic Growth Office of Financial and Insurance Services Securities Section P.O. Box 30701 Lansing, MI 48909 American LegalNet, Inc. www.FormsWorkflow.com FIS 0557 Office of Financial and Insurance Services MICHIGAN DEPARTMENT OF LABOR & ECONOMIC GROWTH OFFICE OF FINANCIAL AND INSURANCE SERVICES Consent to Service of Process KNOW ALL MEN BY THESE PRESENTS: That of (Issuer) a/an (designate whether issuer is an individual or an organization) (number, street, city, state and zip code) for the purpose of complying with the laws of the state of Michigan, hereby irrevocably appoints the Commissioner of the Office of Financial and Insurance Services of the Michigan Department of Labor & Economic Growth, or the Commissioner=s successor in office, to be the applicant=s attorney to receive service of any lawful process in any noncriminal suit, action or proceeding against applicant, its successor, executor or administrator, which may arise under the Michigan Uniform Securities Act (being Act 265 of the Public Acts of 1964, as amended) or any rule or order thereunder after the filing hereof: and the applicant does hereby consent that any such suit, action or proceeding against applicant may be commenced in any court of competent jurisdiction and proper venue within the State of Michigan by service of process upon the said Commissioner with the same force and validity as if served upon the applicant by service personally on its president or other chief officer, if a corporation, or one of its members if a limited liability company, or on one of its partners, if a partnership, or on one of its trustees, if a trust, or on the individual, if an individual. Signature Title Date State of County of Subscribed and sworn to before me this day of A.D. Notary Public County of State of American LegalNet, Inc. www.FormsWorkflow.com
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