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Statement Of Claim For The Exemption Of A Missouri Agricultural Cooperative Form. This is a Missouri form and can be use in Blue Sky Secretary Of State.
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Tags: Statement Of Claim For The Exemption Of A Missouri Agricultural Cooperative, SE-2, Missouri Secretary Of State, Blue Sky
Robin Carnahan
Secretary of State
State of Missouri
Securities Division • 600 W. Main • PO Box 1276
Jefferson City, MO 65102
Statement of Claim for the Exemption of Securities
of a Missouri Agricultural Cooperative
1. Name and principal address of the issuer:
2. Date of organization of the issuer under the Missouri Nonprofit Cooperative Marketing Law:
3. Name, address and telephone number of the correspondent to whom notices and communications regarding the notice filing may
be sent:
4. Has the issuer, or any of its promoters, officers or directors sold securities in Missouri during the last three years?
If yes, please describe and explain how these sales complied with the Missouri securities laws.
5. Please describe the anticipated offering as follows:
Total Offering
Description of Securities
Offering Price
or Proposed
Offering Price
No. of Shares
or Units
Totals
Offering in This State
Amount
$
$
No. of Shares
or Units
Amount
$
$
FORM SE-2 (01-05)
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6. List the states in which the issuer is intending to offer its securities for sale to the public.
7. Does the issuer anticipate paying any commissions or giving any remuneration for effecting the sale of the securities of the
issuer?
If yes, please provide for each individual, name, address, telephone number, current employment relationship with the
issuer or its member, and description of the commissions or other remuneration.
8. List all promoters, officers and directors of the issuer, including their address, position with the issuer and beginning date with
the issuer.
9. Describe the method by which the securities described above will be sold, including any class of persons to whom offers will be
made and the geographic areas in which sales activities will be conducted.
10. The following documents must be submitted as a part of this statement of claim:
(a) Consent to service of process.
(b) Corporate resolution.
(c) Prospectus or offering document in its latest form.
(d) Bylaws, operating agreement or similar document.
(e) Any advertising materials or any summaries of the offering document to be used in the offer or sale of the securities.
(f) Underwriting or selling agreements.
(g) List of agents representing cooperative.
(h) Subscription agreements.
Date
Name of Issuer
By
Name and Title
FORM SE-2 (01-05)
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}
STATE OF
County of
The undersigned,
ss.
, being first duly sworn, deposes and says:
That he has executed the foregoing statement of claim for and on behalf of the issuer named therein, that he is
of such issuer and is fully authorized to execute and file such statement of claim; that he is familiar with such statement of
claim; and that to the best of his knowledge, information and belief the statements made in such statement of claim are true and
the documents submitted therewith are true copies of the originals thereof.
Name
Subscribed and sworn to before me, this
day of
, 20
Notary Public
,
(Notary Seal)
In and for the County of
State of
My Commission Expires:
FORM SE-2 (01-05)
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