Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Issuer Company-Related Action Notification Form. This is a Official Federal Forms form and can be use in FINRA.
Loading PDF...
Tags: Issuer Company-Related Action Notification Form, Official Federal Forms FINRA,
Issuer Company-Related Action Notification Form
Completion of this form certifies to FINRA notification of a corporate action change request for the OTC issuer in compliance with FINRA Rule 6490 and SEA
Rule 10b-17. All notifications are required to be received by FINRA no later than 10 calendar days prior to the effective date of the corporate action.
Processing for the effective time in the market place is determined based upon the satisfactory review of and compliance with all information requested by
FINRA. Please refer to the Required Documentation section for supplemental forms and documentation required to be submitted along with this
notification form.
Company Information
Company Name:
Company Address:
Telephone:
Facsimile:
Website:
Yes, please provide SEC CIK or File Number:
Is or has Company been a SEC Reporting Issuer?
Country of Incorporation:
No
If US, State of Incorporation:
Date of Incorporation or Re-Incorporation:
Is Company in "Good Standing" in its State of Incorporation?
Yes
No, date when Company will become compliant:
Contact Information
Contact Name:
Title:
Name of Firm (If different from Company):
Address (if different from Company):
Telephone:
Facsimile:
Email:
Affiliation with Company:
Company Officers & Directors
Name:
Title:
Date of Appointment:
Name:
Title:
Date of Appointment:
Name:
Title:
Date of Appointment:
Name:
Title:
Date of Appointment:
Are any of the Officers, Directors, or parties related to the company and/or company-related action the subject of pending, adjudicated or settled regulatory
action or investigation by a regulatory body, or civil or ciminal action related to fraud or regulatory body, or civil or criminal action related to fraud or
securities laws violation?
Yes
Please provide a detailed explanation:
No
Page 1 of 9
ISSUER COMPANY-RELATED ACTION NOTIFICATION FORM REV. (09/10)
American LegalNet, Inc.
www.FormsWorkFlow.com
Security Information
Current Issue Symbol:
Current CUSIP:
New CUSIP: (if applicable):
Security Class & Description:
Does issue trade on a foreign exchange?
Yes
Foreign Exchange:
Foreign Issue Symbol:
No
Are you aware of any current trading or clearing restriction by any exchange, government agency, self-regulatory organization or clearing organization
imposed on the company's shares?
Yes
Please specify:
No
Transfer Agency Contact Information
Transfer Agency:
Address:
Agency Representative:
Telephone:
Date of Appointment:
Email:
Facsimile:
Website:
If date of appointment is within last six months, please provide Prior Transfer Agency information below:
Prior Transfer Agency:
Date of Termination:
Prior AgencyAddress:
Prior Agency Representative:
Telephone:
Email:
Facsimile:
Website:
Is the Transfer Agency listed above the same Transfer Agency that will process this corporate action?
Yes
No, please provide the following information for the Transfer Agency that will process this action:
Transfer Agency:
Address:
Agency Representative:
Telephone:
Email:
Facsimile:
Website:
Date of Appointment:
Page 2 of 9
ISSUER COMPANY-RELATED ACTION NOTIFICATION FORM REV. (09/10)
American LegalNet, Inc.
www.FormsWorkFlow.com
Transaction Options
Please check all corporate actions that apply. Additionally please see Sections entitled "FINRA 6490 Fee Schedule" and "Required Documentation" at the end
of the form for applicable fees and list of documents.
Forward Split
Payable Upon Surrender
Forward Stock Split Ratio:
Record Date:
Payable Date:
Mailed Directly to Shareholders
Delivery Date of New Shares:
Total Shares Outstanding Prior to Forward Split:
As of Date:
Number of Additional Shares being Offered:
Total Shares Outstanding After Forward Split:
Method of Settling Fractional Shares:
Yes
Does Transfer Agency have certificates for distribution?
No
Percentage Available for Distribution:
Reverse Stock Split
Reverse Stock Split Ratio:
Record Date:
Payable Date:
Delivery Date of New Shares:
Total Shares Outstanding Prior to Reverse Split:
As of Date:
Number of Shares being Cancelled:
Total Shares Outstanding After Reverse Split:
Method of Settling Fractional Shares:
Does Transfer Agency have certificates for distribution?
Yes
No
Percentage Available for Distribution:
Reverse Stock Split Followed by a Forward Stock Split with a Mandatory Cash Out
Reverse Stock Split Ratio:
Record Date:
Forward Stock Split Ratio:
Payable Date:
Delivery Date of New Shares:
Total Shares Outstanding Prior to Reverse Split:
As of Date:
Number of Shares being Cancelled:
Total Shares Outstanding After Reverse Split:
Number of Additional Shares being Offered with Forward Split:
Total Shares Outstanding After Forward Split:
Method of Settling Fractional Shares:
Does Transfer Agency have certificates for distribution?
Yes
Percentage Available for Distribution:
Page 3 of 9
No
ISSUER COMPANY-RELATED ACTION NOTIFICATION FORM REV. (09/10)
American LegalNet, Inc.
www.FormsWorkFlow.com
Spin-Off
Spin-Off Company Name:
Record Date:
Payment Date:
Distribution Ratio:
Per share valuation of Spin-Off Company (if any):
Spin-Off shares are:
Spin-off shares will be allocated as:
Exempt from SEC Registration
Pending SEC Registration
SEC Registered
Freely Tradable & Restricted Shares
Restricted Shares Only
Freely Tradable Shares Only
is there any action needed by shareholder to receive Spin-Off shares?
Yes, please specify:
No
Are the Spin-Off shares being distributed in a security that is publicly traded?
Yes, please provide the following:
Ticker Symbol:
CUSIP:
Exchange:
No
Dividend/Distribution
Cash
Type of Dividend/Distribution:
Record Date:
Stock
Optional, please specify:
Payment Date:
Cash
Stock
Cash and/or Stock
Declaration Date:
Dividend/Distribution Ratio:
Election Date:
Dividend/Distribution is (Please check one):
Monthly
Quarterly
Semi-Annual
Annual
Special
Other, explain below
Explain any conditions, which must be met (for example, shareholder approval, government approval, SEC registration, etc.) for this distribution to become effective:
Qualified as defined under the provisions of The Jobs and Growth Tax Relief Reconciliation Act of 2003:
Yes
No
Not Known
Dividend Payable in Another Company's Stock
Record Date:
Shares will be allocated as:
Payable Date:
Distribution Ratio:
Freely Tradable Shares Only
Restricted Shares Only
Freely Tradable & Restricted Shares
Are the shares being distributed in a security that is publicly traded?
Yes, please provide the following:
Ticker Symbol:
CUSIP:
Exchange:
No
Does Transfer Agency have certificates for distribution?
Yes
Percentage Available for Distribution:
Page 4 of 9
No
ISSUER COMPANY-RELATED ACTION NOTIFICATION FORM REV. (09/10)
American LegalNet, Inc.
www.FormsWorkFlow.com
Merger/Acquisition
Anticipated effective date of merger:
Yes
Will there be any consideration to shareholders?
No
Cash Consideration:
Name of Company Merging with/Acquiring:
Is the Company you are Merging with/Acquiring a publicly traded company?
Yes, please provide the following:
Ticker Symbol:
CUSIP:
Exchange:
No
Domicile Change
New Country of Incorporation:
If US, State of Incorporation:
Date of Incorporation:
Redemption
Redemption Date:
Total Amount paid per share:
Yes
Has a Broker Protect Period been established?
Amount paid as interest:
No
Amount paid as dividend:
Name Change
New Company Name:
Yes
Is name change the result of a merger, reverse merger or acquisition?
No
Date of Merger:
Legal Effective Date of Name Change:
Rights Offering
Declaration Date:
Record Date:
Expiration Date:
SEC Effective Date:
Are Rights Transferrable?
Yes
No
Is the offering a Poison Pill?
Distribution Date:
Subscription Price:
Yes
No
How many Rights are being distributed on a per share basis?
What does each Right entitle the holder to purchase?
Maximum number of underlying shares to be issued upon exercise of rights:
Page 5 of 9
ISSUER COMPANY-RELATED ACTION NOTIFICATION FORM REV. (09/10)
American LegalNet, Inc.
www.FormsWorkFlow.com
Bankruptcy
Date of Initial Bankruptcy Filing:
Court Established: Confirmation Date:
Effective Date:
Upon effectiveness of the Plan, shares are:
Cancelled with no distributions paid to shareholders
Cancelled with distribution paid to shareholders of record
Payable Upon Surrender of Certificates
DIstribution per share:
Record Date Event, please provide date:
Issued shares of new security
Receive right to purchase new stock
Will there be multiple distributions?
Yes
No
Liquidation
Rate per Share:
How will the distribution be handled?
Payment Date:
Payable Upon Surrender of Certificates
Will there be multiple distributions?
Yes
No
What is the status of the transfer books?
Open
Closed
Record Date Event, please provide date:
is this a Final Distribution?
Yes
No
Date Closed:
Other (please specify):
OTC Voluntary Symbol Request Change
All submissions of OTC Voluntary Symbol Requests must be accompanied by $500, non-refundable fee.
Preference #1:
Preference #2:
Preference #3:
*FINRA will make its best attempt to honor the requests above; however, granting of a symbol is subject to availability. FINRA can give No guarantee that any
of the requests above will be granted.
Page 6 of 9
ISSUER COMPANY-RELATED ACTION NOTIFICATION FORM REV. (09/10)
American LegalNet, Inc.
www.FormsWorkFlow.com
FINRA Rule 6490 Fee Schedule
SEA Rule 10b-17 Action
Fee
Timely SEA Rule 10b-17 Notification Notice Submitted at least 10 calendar days prior to corporate action date
$200
Late SEA Rule 10b-17 Notification
Notice Submitted at least 5 calendar days prior to corporate action date
$1,000
Late SEA Rule 10b-17 Notification
Notice Submitted at least 1 calendar day prior to corporate action date
$2,000
Late SEA Rule 10b-17 Notification
Notice Submitted on or after corporate action date
$5,000
Other Company-Related Action
Fee
$500
Voluntary Symbol Request Change
Initial Symbol Set Up
Action Determination Appeal Fee
Fee
$4,000
No Charge
Symbol Deletion
Appeals
No Charge
Payment of Fee(s)
Payment of FINRA Rule 6490 fees for Issuer Company-Related Actions are to be wired to:
Bank Name:
BNY Mellon
Bank Address:
Philadelphia, PA
ABA Number:
031000037
Account Number:
8-146-524
Bank Address:
Philadelphia, PA
RFB or OBI
See below for derivation*
The RFB or OBI is composed as
follows:
OTC, the securities CUSIP, Current OTC Equity Symbol, and type of Company -Related Action - i.e., OTC123456789ABCDFS
Company-Related Action Types
SC
Symbol Change
RS
Reverse Split
FS
Forward Split
CD
Cash Dividend
SD
Stock Dividend
SO
Spin-Off
RF
Reverse Split followed by Forward Split
SO
Dividend Payable in Another Company's Stock
Page 7 of 9
ISSUER COMPANY-RELATED ACTION NOTIFICATION FORM REV. (09/10)
American LegalNet, Inc.
www.FormsWorkFlow.com
Required Documentation
The following documentation is required to be submitted for the identified Company-Related Actions:
Forward & Reverse Splits, Name Change, Merger/Acquisition, Domicile Change & Dividend Payable in Another Company Stock
Executed and notarized copy of the Board of Directors Resolution authorizing the merger, or SEC filing equivalent, or notarized and executed
officers certificate
Notarized and executed shareholder approval authorizing the distribution. (This may be submitted in the form of a notarized
officer's certificate)
Forward Splits, Reverse Splits, Name Change, Merger/Acquisition & Domicile Change
Letter providing a full corporate history beginning at the original date of incorporation including all corporate changes, but not limited to, changes of
control, reverse mergers, names changes, share exchanges, purchase agreements, etc. that have occurred until present day.
Documents filed with State of Incorporation including, but not limited to, Articles of Incorporation, Certificate of Merger, and Amendment to the Articles
of Incorporation. If not required, please provide specific state law why the item is not required.
Executed and Notarized documents, or SEC equivalent Form filing and date of filing, relating to corporate changes including, but not limited to,
corporate confirmation of Shareholders Consent, Board of Director resolutions, resignation and/or appointment of corporate officers and directors, etc.
For any documents not notarized, please provide a notarized Corporate Officer Certificate attesting to the authenticity of those documents. If not
required, please provide specific state law why the item is not required.
CUSIP confirmation from the CUSIP Service Bureau (212-438-6565 or www.cusip.com) indicating the current status of the cusip for the issue(s). Not
required for Forward Splits Mailed Out Directly.
Forward Splits, Reverse Splits, Name Change, Spin-Off & Merger/Acquisition
Transfer Agent Verification Form completed and submitted by current Transfer Agent. If date of appointment is within last six months, a letter from the
previous Transfer Agent is required indicating status of book and records.
Forward Splits & Reverse Splits
File stamped Articles of Merger
Reverse Splits & Merger/Acquisition
Plan of Merger
Articles of Merger
Merger/Acquisition
An opinion letter from an attorney opining that the entity in question is the same corporate entity and the transaction is otherwise legal..
Bankruptcy
Confirmed Plan of Reorganization
Liquidation
Plan of Liquidation or Dissolution
Stamped Articles of Dissolution filed with State of incorporation
Page 8 of 9
ISSUER COMPANY-RELATED ACTION NOTIFICATION FORM REV. (09/10)
American LegalNet, Inc.
www.FormsWorkFlow.com
Issuer Transparency Caution:
Issuer acknowledges that by completing a forward stock split resulting in a per share price of less than $.0001, the issuer's stock will not be quotable in most
OTC quotation media (including the OTCBB). Issuer further acknowledges that by completing a forward stock split resulting in a per share price of less than
$.000001, trades in the issuer's stock will not be eligible for electronic trade reporting to the FINRA OTC reporting facility.
Authorization by Corporate Officer
I *,
*Required Field
, hereby certify that the information disclosed in this request is accurate and true.
(print name)
SIGNATURE:*
DATE:*
Submission of Notification and Supporting Documentation
FINRA
Operations, 5th Floor
9509 Key West Avenue
Rockville, MD 20850
Telephone: 1.866.776.0800, Option 1
Fax: 202.689.3533
E-mail: OTCcorpactions@finra.org
Print Form
Page 9 of 9
ISSUER COMPANY-RELATED ACTION NOTIFICATION FORM REV. (09/10)
American LegalNet, Inc.
www.FormsWorkFlow.com