Report On Sales Of Securities Form. This is a Pennsylvania form and can be use in Blue Sky Department Of State.
Tags: Report On Sales Of Securities, 209, Pennsylvania Department Of State, Blue Sky
Form 209 TDD/AT&T Relay Center: 1-800-654-5984 Instructions EFFECTIVE: 10/11/97 REVISED: 12/23/04 PENNSYLVANIA SECURITIES COMMISSION Eastgate Office Building, 2nd Floor, 1010 N. 7th Street Harrisburg, PA 17102-1410 (717) 787-8061 (1-800-600-0007 in PA) REPORT ON SALES OF SECURITIES GENERAL INSTRUCTIONS W HO M UST FILE: Issuers which have sold securities in Pennsylvania pursuant to registration by qualification under Section 206, EXCEPT where the offering is registered under Section 5 of the Securities Act of 1933 AND the maximum fee has been paid (see Section 602(b)(iii)). W HEN TO FILE: File Form 209 within 420 days after the effective date of the registration statement in Pennsylvania. 1. For a further explanation of terms used in the Form, refer to Section 102 of the Pennsylvania Securities Act of 1972 (“1972 Act”). 2. One manually signed copy of the Form with all attachments shall be filed with the Commission. If mailed, it is advisable to send it by registered or certified mail, postage prepaid, return receipt requested. 3. Typewrite or print all answers in the space provided. Answer each item completely. An answer of "not applicable" is inappropriate. If the space is insufficient, attach a schedule to the Form and make reference to each item included in the schedule. 4. The Form filed with the Commission must be manually signed by the issuer. If the issuer is a corporation, it should be signed in the name of the corporation by an executive officer duly authorized; if a partnership, it should be signed in the name of the partnership by a general partner; and if an unincorporated association or other organization not a partnership, this Form should be signed in the name of such organization by a person responsible for the direction or management of its affairs. 5. In the event that, at any time after the filing of the Form, the issuer becomes aware that any information provided on the Form becomes inaccurate in any material respect, the issuer shall file an amendment with the Com mission within 5 business days from the date the issuer became aware that the information previously submitted was inaccurate at the time it was filed. 6. In lieu of answering any specific question in the Form, the issuer may incorporate by reference information contained in any document attached thereto or previously on file with the Commission. Any such reference should be to the page and paragraph number or other specified portion of the document where the information is located. 7. Please remove instruction sheet before filing this Form . 33 American LegalNet, Inc. www.FormsWorkflow.com FILE NO.:________________________ FORM 209 EFFECTIVE: 10/11/97 REVISED: 12/23/04 COM M ONW EALTH OF PENNSYLVANIA PENNSYLVANIA SECURITIES COM M ISSION PART I Issuer Information 1. Exact Name of Issuer: _____________________________________________________________________ 2. Address of Principal Office of Issuer:________________________________________________________ Number and Street _________________________________________________________________________________________ City State Zip Code Telephone No. 3. Name and address of person to whom correspondence regarding this filing should be sent: _________________________________________________________________________________________ Name Title Number and Street _________________________________________________________________________________________ City State Zip Code Telephone No. PART II Report of Sales of Securities Registered under Section 206. 4. Date of effectiveness of registration statement under Section 206_______________________________ 5. (A) Offering in Pennsylvania: (i) Total number of shares or other units: _______________________________________________ (ii) Per share or unit price: ____________________________________________________________ (iii) M aximum aggregate offering price: _________________________________________________ (B) Sales in Pennsylvania: (i) Number of shares or other units: ___________________________________________________ (ii) Aggregate proceeds received:_______________________________________________________ Each of the persons executing this report on behalf of the Issuer hereby affirms that the statements made herein, including all attachments hereto, are not incomplete in any material respect or false or misleading with respect to any m aterial fact. Each of such persons further affirms that he is familiar with the penalties contained in the Pennsylvania Securities Act of 1972, and all regulations adopted thereunder for m aking any false or incomplete statement in connection with the sale of a security or in any filing with the Commission. IN WITNESS W HEREOF, this report has been executed on ___________________________________. (insert date) _______________________________________________ (Name of Issuer) By: ___________________________________________ (Title) 34 American LegalNet, Inc. www.FormsWorkflow.com