Michigan > Secretary Of State > Blue Sky > Securities > Securities Filing
Statement Demonstrating Eligibility For Registration By Notification FIS-0565 - Michigan
| Statement Demonstrating Eligibility For Registration By Notification Form. This is a Michigan form and can be used in Securities Filing Securities Blue Sky Secretary Of State . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
FIS 0565 (5/04) Office of Financial and Insurance Services This form is issued under Act 265, PA 1964, as amended. You must complete and submit this form if you wish to make an application for registration under Section 302 of the Act. STATEMENT DEMONSTRATING ELIGIBILITY FOR REGISTRATION BY NOTIFICATION 1. Name of Issuer If making application under Sec. (a)(1), then answer questions 2 to 6, inclusive. 2. How long has the issuer been in continuous operation? If less than 5 years, give names of predecessor and state length of time each has been in continuous operation: 3. Has there been any default during the current fiscal year or within the 3 preceding fiscal years in the payment of principal, interest, or dividends on any security of the issuer, or any predecessor, with a fixed maturity or a fixed interest or dividend provision? YES NO 4. Give the following information as to all securities without a fixed maturity or a fixed interest or dividend provision: Class of Securities Now Outstanding No. of Units Maximum Offering Price per Unit * Market Price per Unit * Book Value Per Unit ** Amount *** $ $ $ $ Total $ * The maximum offering price or the market price may be on a day selected by the applicant but must be within 30 days before the date of filing this registration statement. ** Book value must be on a day, selected by the applicant, but must be within 90 days of filing this registration statement but may be used only if there is neither a readily determinable market price or a cash offering price. (If book value is used, attach balance sheet from which the same is determined.) *** The amount extended is the product of either (1) the number of units times the higher of the maximum offering price or the market price, or (2) the number of units times the book value. 5. If none of the classes of securities now outstanding listed in answer to Question 4 were outstanding securities of the issuer or any of its predecessors for 3 full years, then complete the schedule below following the footnoted instructions in Question 4. Class of Securities Now Outstanding No. of Units Maximum Offering Price per Unit Market Price per Unit Book Value Per Unit Amount $ $ $ $ Total $ American LegalNet, Inc. www.FormsWorkflow.com Include all securities which will be outstanding if all the securities being offered or proposed to be offered are issued, whether or not they are proposed to be registered or offered in this state. 6. State net earnings of the issuer and any predecessors during the past 3 fiscal years, determined in accordance with generally accepted accounting practices which are applicable to all securities without a fixed maturity or a fixed interest or dividend provision. (These must be figures pursuant to certified audit with evidence thereof attached.) Net Earnings Fiscal Year Ended Fiscal Year Ended Fiscal Year Ended Total Average (1/3) 5% of total in Question 4 is 5% of total in Question 5 is $ $ $ $ $ If the Securities comply with Sec. 302(a)(2), then answer Question 7. 7. If this is a non-issuer distribution and is not being registered under Sec. 302(a)(1), then state (a) if any security of this class has ever been previously registered under this act or a predecessor act. (Give details including date.) or (b) if the security being registered was originally issued pursuant to an exemption under this act or a predecessor act. (Give details including date) Signature of officer, member, partner, or proprietor Title Date American LegalNet, Inc. www.FormsWorkflow.com
|
|||||||
