Notification And Report Form For Certain Mergers And Acquisitions {C4} | Pdf Fpdf Doc Docx | Official Federal Forms

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Notification And Report Form For Certain Mergers And Acquisitions {C4} | Pdf Fpdf Doc Docx | Official Federal Forms

Notification And Report Form For Certain Mergers And Acquisitions {C4}

This is a Official Federal Forms form that can be used for Premerger Notification Office within Federal Trade Commission.

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16 C.F.R. Part 803 - Appendix NOTIFICATION AND REPORT FORM FOR CERTAIN MERGERS AND ACQUISITIONS TRANSACTION NUMBER ASSIGNED FEE INFORMATION AMOUNT PAID $ (For Payer Only) TAXPAYER IDENTIFICATION NUMBER OR SOCIAL SECURITY NUMBER FOR NATURAL PERSONS In cases where your filing fee would be higher if based on acquisition price or where the acquisition price is undetermined to the extent that it may straddle a filing fee threshold, attach an explanation of how you determined the appropriate fee. Attachment number: NAME OF PAYER (if different from PERSON FILING) WIRE TRANSFER or CERTIFIED CHECK / MONEY ORDER ATTACHED WIRE TRANSFER CONFIRMATION NO. FROM (NAME OF INSTITUTION) IS THIS A CORRECTIVE FILING? YES NO CASH TENDER OFFER? YES NO BANKRUPTCY? YES NO DO YOU REQUEST EARLY TERMINATION OF THE WAITING PERIOD? YES NO (Grants of early termination are published in the Federal Register and on the FTC web site, www.ftc.gov) YES NO IF YES, list jurisdictions: (voluntary) IS THIS ACQUISITION SUBJECT TO NON-US FILING REQUIREMENTS? ITEM 1 1(a) PERSON FILING NAME HEADQUARTERS ADDRESS ADDRESS LINE 2 CITY, STATE, COUNTRY ZIP CODE WEB SITE 1(b) PERSON FILING NOTIFICATION IS an acquiring person an acquired person both 1(c) PUT AN "X" IN THE APPROPRIATE BOX TO DESCRIBE THE PERSON FILING NOTIFICATION Corporation Unincorporated Entity Natural Person Other (Specify) 1(d) DATA FURNISHED BY calendar year fiscal year (specify period): (month/year) to (month/year) 1(e) PUT AN "X" IN THE APPROPRIATE BOX BELOW AND GIVE THE NAME AND ADDRESS OF THE ENTITY FILING NOTIFICATION, IF DIFFERENT THAN THE ULTIMATE PARENT ENTITY Not Applicable This report is being filed on behalf of a foreign person pursuant to § 803.4. This report is being filed on behalf of the ultimate parent entity by another entity within the same person authorized by it to file pursuant to § 803.2(a). NAME ADDRESS CITY, STATE, COUNTRY ZIP CODE 1(f) NAME AND ADDRESS OF ENTITY MAKING ACQUISITION OR WHOSE ASSETS, VOTING SECURITIES OR NON-CORPORATE INTERESTS ARE BEING ACQUIRED, IF DIFFERENT FROM THE ULTIMATE PARENT ENTITY IDENTIFIED IN ITEM 1(a) NAME ADDRESS CITY, STATE, COUNTRY ZIP CODE Not Applicable PERCENT OF VOTING SECURITIES OR NON-CORPORATE INTERESTS THAT THE UPE HOLDS DIRECTLY OR INDIRECTLY IN THE ACQUIRING OR ACQUIRED ENTITY IDENTIFIED IN ITEM 1(f) 1(g) IDENTIFICATION OF PERSONS TO CONTACT REGARDING THIS REPORT CONTACT PERSON 1 FIRM NAME BUSINESS ADDRESS CITY, STATE, COUNTRY ZIP CODE TELEPHONE NUMBER FAX NUMBER E-MAIL ADDRESS CONTACT PERSON 2 FIRM NAME BUSINESS ADDRESS CITY, STATE, COUNTRY ZIP CODE TELEPHONE NUMBER FAX NUMBER E-MAIL ADDRESS % 1(h) IDENTIFICATION OF AN INDIVIDUAL LOCATED IN THE UNITED STATES DESIGNATED FOR THE LIMITED PURPOSE OF RECEIVING NOTICE OF ISSUANCE OF A REQUEST FOR ADDITIONAL INFORMATION OR DOCUMENTS (See § 803.20(b)(2)(iii)) NAME FIRM NAME BUSINESS ADDRESS CITY, STATE, COUNTRY ZIP CODE TELEPHONE NUMBER FAX NUMBER E-MAIL ADDRESS FTC FORM C4 (rev. 08/18/2011) Page 1 of 10 American LegalNet, Inc. www.FormsWorkFlow.com 16 C.F.R. Part 803 - Appendix NAME OF PERSON FILING NOTIFICATION DATE ITEM 2 2(a) LIST NAMES OF ULTIMATE PARENT ENTITIES OF ALL ACQUIRING PERSONS NAME NONREPORTABLE LIST NAMES OF ULTIMATE PARENT ENTITIES OF ALL ACQUIRED PERSONS NAME NONREPORTABLE 2(b) THIS ACQUISITION IS (put an "X" in all the boxes that apply) an acquisition of assets a merger (see § 801.2) an acquisition subject to § 801.2 (e) a formation of a joint venture or other corporation or unincorporated entity (see § 801.40 or § 801.50) an acquisition subject to § 801.30 (specify type) a consolidation (see § 801.2) an acquisition of voting securities a secondary acquisition an acquisition subject to § 801.31 an acquisition of non-corporate interests other (specify) 2(c) INDICATE THE HIGHEST NOTIFICATION THRESHOLD IN § 801.1(h) FOR WHICH THIS FORM IS BEING FILED (acquiring person only in an acquisition of voting securities) $50 million (as adjusted) $100 million (as adjusted) $500 million (as adjusted) 25% (see Instructions) (as adjusted) 50% N/A 2(d)(i) VALUE OF VOTING SECURITIES ALREADY HELD ($MM) (v) VALUE OF NON-CORPORATE INTERESTS ALREADY HELD ($MM) $ (ii) PERCENTAGE OF VOTING SECURITIES ALREADY HELD $ (vi) PERCENTAGE OF NON-CORPORATE INTERESTS ALREADY HELD % (iii) TOTAL VALUE OF VOTING SECURITIES TO BE HELD AS A RESULT OF THE ACQUISITION ($MM) % (vii) TOTAL VALUE OF NON-CORPORATE INTERESTS TO BE HELD AS A RESULT OF THE ACQUISITION ($MM) (ix) VALUE OF ASSETS TO BE HELD AS A RESULT OF THE ACQUISITION ($MM) $ (iv) TOTAL PERCENTAGE OF VOTING SECURITIES TO BE HELD AS A RESULT OF THE ACQUISITION $ (viii) TOTAL PERCENTAGE OF NONCORPORATE INTERESTS TO BE HELD AS A RESULT OF THE ACQUISITION $ (x) AGGREGATE TOTAL VALUE ($MM) % FTC FORM C4 (rev. 08/18/2011) Page 2 of 10 %$ 16 C.F.R. Part 803 - Appendix American LegalNet, Inc. www.FormsWorkFlow.com NAME OF PERSON FILING NOTIFICATION DATE ITEM 3 3(a) DESCRIPTION OF ACQUISITION ACQUIRING UPE(S) NAME ADDRESS ADDRESS LINE 2 CITY, STATE ZIP CODE, COUNTRY ACQUIRED UPE(S) NAME ADDRESS ADDRESS LINE 2 CITY, STATE ZIP CODE, COUNTRY ACQUIRING ENTITY(S) NAME ADDRESS ADDRESS LINE 2 CITY, STATE ZIP CODE, COUNTRY ACQUIRED ENTITY(S) NAME ADDRESS ADDRESS LINE 2 CITY, STATE ZIP CODE, COUNTRY TRANSACTION DESCRIPTION 3(b) SUBMIT A COPY OF THE MOST RECENT VERSION OF THE CONTRACT OR AGREEMENT (or letter of intent to merge or acquire) (IF SUBMITTING PAPER, DO NOT ATTACH THE DOCUMENT TO THIS PAGE) ATTACHMENT NUMBER FTC FORM C4 (rev. 08/18/2011) Page 3 of 10 16 C.F.R. Part 803 - Appendix American LegalNet, Inc. www.FormsWorkFlow.com NAME OF PERSON FILING NOTIFICATION DATE ITEM 4 PERSONS FILING NOTIFICATION MAY PROVIDE BELOW AN OPTIONAL INDEX OF DOCUMENTS REQUIRED TO BE SUBMITTED BY ITEM 4 (See Item by Item instructions). THESE DOCUMENTS SHOULD NOT BE ATTACHED TO THIS PAGE. 4(a) ENTITIES WITHIN THE PERSON FILING NOTIFICATION THAT FILE ANNUAL REPORTS WITH THE None SECURITIES AND EXCHANGE COMMISSION CENTRAL INDEX KEY NUMBER 4(b) ANNUAL REPORTS AND ANNUAL AUDIT REPORTS None ATTACHMENT OR REFERENCE NUMBER 4(c) STUDIES, SURVEYS, ANALYSES, AND REPORTS None ATTACHMENT OR REFERENCE NUMBER 4(d) ADDITIONAL DOCUMENTS None ATTACHMENT OR REFERENCE NUMBER FTC FORM C4 (rev. 08/18/2011) Page 4 of 10 16 C.F.R. Part 803 - Appendix American LegalNet, Inc. www.FormsWorkFlow.com NAME OF PERSON FILING NOTIFICATION DATE ITEM 5 5(a) DOLLAR REVENUES BY NON-MANUFACTURING INDUSTRY CODE AND BY MANUFACTURED PRODUCT CODE Check None at the bottom of the

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