Pennsylvania SOI Supplement Form. This is a Pennsylvania form and can be use in Blue Sky Department Of State.
Tags: Pennsylvania SOI Supplement, SOIS, Pennsylvania Department Of State, Blue Sky
NOTE TO USERS: The following form sets forth the minimum informational requirement for soliciting indications of interest under the Pennsylvania Securities Act of 1972 (1972) when used in conjunction with Form SOI. You may include additional information if you think it necessary or desirable. Remember that any discussion in this document is subject to the anti-fraud provisions of the 1972 Act and must therefore be complete. You may not exaggerate the investment opportunity, minimize the risks of the enterprise or predict revenues, profits or payment of dividends (including financial projections and forecasts). The information in the Pennsylvania SOI Supplement is an integral part of the SOI Form and MUST accompany the SOI Form information at all times and under all circumstances. PENNSYLVANIA SOI SUPPLEMENT NAME OF COMPANY Check the appropriate response(s) 1. The securities the issuer proposes to offer are: a. Common Stock b. Preferred or Preference Stock c. Notes, Debentures or Bonds d. Limited Liability Company Membership Interests e. Units of two or more types of securities, composed of: f. Other (specify): 2. These securities will have: a. Cumulative voting rights b. Other special voting rights c. Preemptive rights to purchase any new issue of shares d. Preference as to dividends or interest e. Preference upon liquidation f. Anti-dilution rights g. Other special rights or preferences h. Conversion rights Explain any items checked. Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 3. The issuer's revenues during the last full fiscal year were: a. Less than $10,000 . . . . . b. $10,000 or more but less than $50,000 c. $50,000 or more but less than $250,000 d. $250,000 or more but less than $1 million e. $1 million or more f. . Issuer has been in existence for less than a full fiscal year 4. The issuer had a profit or loss during its last full fiscal year of: a. PROFIT OF: Less than $10,000 . . . $10,000 or more but less than $50,000 $50,000 or more but less than $250,000 $250,000 or more b. LOSS OF: Less than $10,000 . . . . . $10,000 or more but less than $50,000 $50,000 or more but less than $250,000 $250,000 or more . c. Issuer has been in existence for less than a full fiscal year 5. The average price per share of stock paid in cash by the issuer's current shareholders was: a. Less than $.01 . . . . . b. $.01 or more but less than $.05 c. $.05 or more but less than $.10 d. $.10 or more but less than $.25 e. $.25 or more but less than $1.00 f. $1.00 or more . 6. The issuer has engaged in the following transactions with its officers, directors, 10% shareholders or their affiliates or relatives: a. Issued securities in exchange for property or services b. Loaned money . . . . c. Rented or purchased property d. Purchased or sold goods or services e. No such transactions have occurred . Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 7. During the last full fiscal year, the issuer's officers and directors received combined aggregate cash compensation of: a. Less than $50,000 . . . . b. $50,000 or more but less than $100,000 c. $100,000 or more but less than $250,000 d. $250,000 or more but less than $500,000 e. $500,000 or more . 8. Are there any outstanding options or warrants held by current shareholders? YES NO . . 9. Does the issuer's liabilities currently exceed the fair market value of its assets? YES NO . . 10. Is the issuer now, or in the past two years was it, unable to meet its obligations as and when they become due in the usual course of business? YES NO . . Please be advised that all representations in this application are subject to the penalties of 18 Pa. C.S. §4904 (relating to unsworn falsification to authorities). Furthermore, your application will be considered a document filed with the Department of Banking and Securities for purposes of Section 407 of the 1972 Act, 70 P.S. §1-407. IN WITNESS WHEREOF, this report has been executed on (insert date) (Name of Issuer) By: Title: Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com