Regulation 8.130 Transaction Reporting Form

REGULATION 8.130 TRANSACTION REPORTING FORM LICENSEE INFORMATION Licensee number Legal name Trade name Address Individual to contact/title Phone number ( ) TRANSACTION TYPE Loan Lease Guaranty Capital Contribution Donation of Property Conversion of Accounts Payable To a Note If other than above, please specify____________________________________________ Does a written agreement exist to support this transaction? Yes No INFORMATION ON OTHER PARTY TO THE CONTRACT Name of lender, lessor or other (indicate relationship) Address Submit copy of agreement. NOTE: A supplemental information form may need to be completed for certain parties to the transaction. See instructions for additional information. DESCRIPTION OF TRANSACTION Transaction Date Transaction Amount Purpose Interest Rate (if applicable) Payment Amount and frequency Fair Market Value of Property (see instructions) If this transaction is a modification or renewal of a previously filed transaction, please indicate the date of the original transaction and describe any changes: Revised 05/2009 American LegalNet, Inc. www.FormsWorkFlow.com Regulation 8.130 Transaction Reporting Form Page 2 Collateral and Guaranties - Please describe any collateral or guaranties used to secure this transaction. Identify legal owner of any collateral. Attach a copy of any relevant agreement. Other Parties - Please list any endorsers, co-signers or participants. Include name and address of other party(ies) and a description of the person's or entity's involvement. Was a finder's fee paid? Yes Amount _______No Note: Regulation 5.120 defines finder's fees and requires that advance approval be obtained before paying the fee. If this filing is delinquent, please provide an explanation: I __________________________ (print name) do hereby swear under penalty of perjury that I am the ______________________(print title) of the legal entity reporting this transaction and that, to the best of my knowledge and belief, the assertions contained in these documents are true, accurate and complete. NOTE: Form must be signed by an owner, corporate officer or key employee as defined in Regulation 3.110. __________________________ Signature __________________________ Date Revised 05/2009 American LegalNet, Inc. www.FormsWorkFlow.com