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Notification Filing Form. This is a New York form and can be use in Blue Sky Secretary Of State.
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Tags: Notification Filing, 99, New York Secretary Of State, Blue Sky
OFFICE OFATTORNEY GENERAL STATE OF NEW YORKDEPARTMENT OF LAW File # NY FORM 99 INVESTOR PROTECTION BUREAU / REAL ESTATE FINANCE BUREAU NOTIFICATION FILING Submission to: INVESTOR PROTECTION BUREAU (223IPB224) Securities Theatrical SyndicationsREAL ESTATE FINANCE BUREAU (223REF224)Type of Filing: New FilingAmendment or Renewal (If name, address or offering has changed, indicate change and date):A.BASIC IDENTIFICATION DATAFull Name of Issuer (and Theatrical Production Company, if applicable): Address of Executive Offices: Telephone Number ( ) - (Number and Street) (City or Town) (State & ZIP) Type of Organization: business corporation limited liability company limited partnershipnot-for-profit corporationbusiness trustpolitical subdivision of state common fundstate agency or authoritycounty, city, town or village (agency, authority or instrumentality corporation)other (specify):Category of 223Covered Security224: Offering to 223Qualified Purchasers224 [1933 Act* 24718(b)(3)]Rule 506 Offering [1933 Act* 247 4(2) - per 24718(b)(4)(D)]Regulation A, Tier 2 Offering [1933 Act* 2473(b)(2) - per 247247 18(b)(3) & 18(b)(4)(D)(ii)]Other qualifying offering (specify):*Securities Act of 1933, as amendedThe Securities Will Be Sold By: officers or directors of issuer salespersons employed by issuer officers or directors of an affiliated personunderwriter, dealer or broker registered in New YorkFor Theatrical Syndication Offerings, add the following information: Name of proposed production: Location of production: Proposed opening date: IPB/REF99 (rev. American LegalNet, Inc. www.FormsWorkFlow.com IPB/REF99 (rev. 2 B.INFORMATION ABOUT OFFERINGTotal Offering Amount (maximum) $ Type of Security Offered (brief description): Minimum Offering Amount $ Enclosures (add additional sheets if necessary): Copy of Consent to Service of Process (U-2) (original to New York State Department of State, Albany NY)Offering Documents Confidential Attachment to Form 99Further information as to issuer affiliated personsForm D: copy 223as filed224 with the S.E.C 223as filed224 copy will followForm 1-ATheatrical Venture Amendment - Required Supplemental InformationC.INFORMATION ABOUT ISSUER, PRINCIPALS AND CONTROLLING PERSONS225As to issuer: 1.Is issuer subject to or a respondent in any legal action for, any injunction, cease-and-desist order or order orstipulation to desist or refrain from any act or practice relating to the offering of securities in New York or anyother jurisdiction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No2.(a) Has issuer ever been convicted of or pleaded guilty to any crime (i) involving any fraud, or(ii)relating to any financial transactiono r handlingoffundsofano t he r person, o r (iii) pertaining to any dealings in any securities? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No(b) Is issuer now a defendant in any such criminal proceeding? . . . . . . . . . . . . . . . . . . . . . Yes No225As to each Principal*, each Controlling Person, and any Sponsoring Entity of issuer: 3.Is any one of the above subject to or a respondent in any legal action for, any injunction, cease-and-desistorder or order or stipulation to desist or refrain from any act or practice relating to the offering of securities inNew York or any other jurisdiction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No4.(a) Has any one of the above ever been convicted of or pleaded guilty to any crime (i) involving any fraud, or(ii)relating to any financial transaction or handling of funds of another person, or(iii) pertaining to any dealings in any securities? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No(b) Is any one of the above now a defendant in any such criminal proceeding ? . . . . . . . . . Yes No5.Has any of the above ever been suspended or expelled from membership in any securities or commoditiesexchange or association or had a securities or commodities license or registration denied, suspended orrevoked? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No6.Has any of the above been a controlling person or sponsor with respect to any issuer which engaged in adistribution of securities or any public offering within the past three (3) years? . . . . . . . . . Yes No If the answer to any of the above is 223yes224, give material facts on an attached sheet. *Capitalized terms are defined in Section E of Form 99. American LegalNet, Inc. www.FormsWorkFlow.com IPB/REF99 (rev. ) 3 D.CERTIFICATIONThe undersigned affirms and certifies, to his or her knowledge and belief after due investigation and inquiry, and under penalty of perjury, that any and all information provided in this Form 99 is true and complete, and that there are no misrepresentations, omissions or untruths contained herein. The undersigned further understands and intends that the information supplied in this Form will be relied upon by the New York State Department of Law and that any false statement made herein is punishable as a Class A misdemeanor under New York Penal Law 247175.30, 247210.45, or both.Dated:,20 Issuer (name of entity): By: Authorized Principal or Controlling Person Print Name: Title or Affiliation: American LegalNet, Inc. www.FormsWorkFlow.com IPB/REF99 (rev. 4ATTACHMENT TO FORM 99Issuer Name: Form 99 dated: , 20 Identity of Principals (i) of issuer, (ii) of Controlling Person(s)* and (iii) of Sponsoring Entity: Person/Company Name Date of Birth/Organization Social Security/Tax ID Number Amendments: Additions or Deletions of Principals with Effective Date of Change Person/Company Name Date of Birth/Organization Social Security/Tax ID Number Effective Date *Capitalized terms are defined in Section E of Form 99. American LegalNet, Inc. www.FormsWorkFlow.com IPB/REF99 (rev.) 5 E.INSTRUCTIONS1.General Instructions.Who May File: All persons engaging in an offering of or transaction in securities within or from New York which are defined as 223covered securities224 (other than 223listed securities224 or open-end management type companies registered with the S.E.C. under the Investment Company Act of 1940 (the 2231940 Act224)) under 24718 of the 1933 Act, as amended. No filing is required for listed securities. Open-end management type companies registered within the S.E.C. under the 1940 Act must file Form NF; other registered investment companies may file Form NF instead of Form 99. An issuer entitled to submit a Notification Filing for transactions, not involving real estate securities, may elect to file instead with IP an M-11 Issuer Statement under GBL 247359-e or an application for exemption under 247359-f(2). Where To File: Address for both Bureaus - ,New York, NY 10 (a)IP if: (i)within New York General Business Law (223GBL224) 247359-e(ii)within ACAL 24723.03 et seq. (b)REF if: (iii)real estate securities or other securities deemed within purview of GBL 247352-e or 247352-gWhen To File: Prior to any sale or offer for sale of securities in or from New York. For theatrical ventures, supplemental statements (in the form of Amendment to Form 99) must be filed advising the Department of Law of (i) date of the first expenditure of investors222 funds, and (ii) date of the last public performance, if any, of the original production in New York State. Such Amendment must be submitted within ten (10) business days of the occurrence. Copies Required: Two (2) copies of Form 99 must be filed, one of which must be manually signed, along with a photocopy of the manually signed copy. One (1) copy of the Offering Documents must also be filed. Information Required: A new filing must contain all information requested. Amendments require only notification of changes with respect to information given in Form 99. Form D: In addition to Form 99, submit a copy of Form D as filed. In the event that Form D has not yet been filed with the S.E.C., submit a copy of the unfiled Form D and provide information as to when such filing will be effected (223as filed224 copy must be submitted when