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Model Accredited Investor Exemption Uniform Notice Of Transaction Form. This is a Connecticut form and can be use in Blue Sky Secretary Of State.
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Tags: Model Accredited Investor Exemption Uniform Notice Of Transaction, MAIE, Connecticut Secretary Of State, Blue Sky
STATE OF CONNECTICUT
DEPARTMENT OF BANKING
SECURITIES AND BUSINESS INVESTMENTS DIVISION
260 CONSTITUTION PLAZA • HARTFORD, CT 06103-1800
MODEL ACCREDITED INVESTOR EXEMPTION
UNIFORM NOTICE OF TRANSACTION
NOTICE OF SALE OF SECURITIES PURSUANT TO ACCREDITED
INVESTOR EXEMPTION
1.
Issuer Name:
Address:
Phone No.:
2.
Form of Organization (Check one):
(
) Corporation
(
) Limited Liability Company
(
) Limited Partnership
(
) Unincorporated Association
(
) Other (Specify)
Issuer's state of incorporation or jurisdiction of organization:
Date of incorporation of organization:
3.
Officers and directors (or persons acting in a similar capacity). Include
Names, Addresses and Phone Numbers:
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4.
This Offering:
Description of
Security
Price Per Security
Number of
Securities
to be
Offered
Aggregate
Dollar
Amount
Debt
Equity (common
or preferred)
Convertible
Security
Partnership
Interests/Other
(Specify)
5.
Description of Business:
6.
Name of Broker-dealer who has solicited or intends to solicit purchasers in
this state.
Address:
By filing this Notice of Transaction, the Issuer of these securities hereby
represents that: (1) Sales of securities shall be made only to accredited investors
as defined in 17 CFR 230.501(a); (2) the Issuer is not an issuer in the development
stage that either has no specific business plan or purpose or has indicated that its
business plan is to engage in a merger or acquisition with an unidentified
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company or companies, or other entity or person; and (3) the Issuer reasonably
believes that all purchasers are purchasing for investment and not with the view
to or for sale in connection with a distribution of the security. Any resale of a
security sold in reliance on this exemption within 12 months of sale, except a
resale to an accredited investor or pursuant to a registration statement effective
under applicable state securities law, shall be presumed to be with a view to
distribution and not for investment. Securities issued under this exemption may
only be resold pursuant to registration or an exemption under applicable state
securities law.
The undersigned represents that the Issuer is familiar with the conditions that
must be satisfied to be entitled to the Accredited Investor Exemption of the state
in which this notice is filed and understands that the Issuer claiming the
availability of this exemption has the burden of establishing that these conditions
have been satisfied.
The Issuer has read this notification and knows the contents to be true and has
duly caused this notice to be signed on its behalf by the undersigned duly
authorized person.
Issuer (Print or type):
Signature:
Name (Print or type):
Title (Print or type):
Date:
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