Crowdfunding Exemption Notice Form. This is a Texas form and can be use in Blue Sky Secretary Of State.
Tags: Crowdfunding Exemption Notice, 133.17, Texas Secretary Of State, Blue Sky
Form 133.17 Texas State Securities Board P.O. Box 13167 Austin, Texas 78711-3167 Crowdfunding Exemption Notice (§139.25) The exemption provided in §139.25 is available only to issuers organized and based in Texas, and all offers and sales of securities under the exemption must be limited to Texas residents. This form is due before any Internet website is used in connection with an offering of securities in reliance on §139.25. All provisions of §139.25 should be reviewed carefully for compliance with the rule. 1. Issuer and offering information (the issuer is the entity issuing securities): Name of issuer: Address: Telephone: Email: Website address where the issuer's securities will be offered: Identify the general dealer or Texas crowdfunding portal operating the website: Amount of the offering: $ Name and address of the bank or other depository institution where investors' funds are to be deposited: 2. Contact to whom communications regarding this Notice should be directed: Name: Address: Telephone: Email: 11-17-2014 American LegalNet, Inc. www.FormsWorkFlow.com Form 133.17 3. Issuer's predecessors, owners, officers, directors, and control persons. In the chart that follows, list the names of the following persons: a. Any predecessor of the issuer; b. Each officer, director, or other person having the power, directly or indirectly, to direct the management or policies of the Issuer, whether by contract or otherwise; and c. Each person that owns, beneficially owns, has the right to vote, or has the power to sell or direct the sale of 20% or more of a class of the Issuer's voting securities. For purposes of this provision, a person beneficially owns any securities: (i) owned by his/her child, stepchild, grandchild, parent, stepparent, grandparent, spouse, sibling, mother-in-law, father-in-law, son-inlaw, daughter-in-law, brother-in-law, or sister-in-law, sharing the same residence; or (ii) that he/she has the right to acquire, within 60 days, through the exercise of any option, warrant, or right to purchase the security. Complete the Title/Status column by entering predecessor or board/management titles; status as partner, trustee, sole proprietor, elected manager, shareholder, or member; and for shareholders or members, the class of securities owned (if more than one is issued). Enter an ownership code if applicable. Ownership codes are: A - Less than 20% B - 20% or more but less than 50% C - 50% or more but less than 75% D - 75% or more Full Name Title / Status Ownership Code 11-17-2014 American LegalNet, Inc. www.FormsWorkFlow.com Form 133.17 Full Name Title / Status Ownership Code By filing this Crowdfunding Exemption Notice, the issuer of these securities hereby represents that the issuer; the issuer's predecessors; any affiliated issuer; the issuer's directors, officers, control persons: · has not within the last five years, filed a registration statement which is the subject of a currently effective registration stop order entered by any state securities administrator or the United States Securities and Exchange Commission; has not within the last five years, been convicted of any criminal offense in connection with the offer, purchase, or sale of any security, or involving fraud or deceit; is not currently subject to any state or federal administrative enforcement order or judgment, entered within the last five years, finding fraud or deceit in connection with the purchase or sale of any security; or is not currently subject to any order, judgment, or decree of any court of competent jurisdiction, entered within the last five years, temporarily, preliminarily, or permanently restraining or enjoining such party from engaging in or continuing to engage in any conduct or practice involving fraud or deceit in connection with the purchase or sale of any security. · · · The undersigned represents that the issuer is familiar with the conditions that must be satisfied to be entitled to the Intrastate Crowdfunding Exemption and understands that the issuer claiming the availability of this exemption has the burden of establishing that these conditions have been satisfied. The issuer has read this Notice and knows the contents to be true and has duly caused this Notice to be signed on its behalf by the undersigned duly authorized person. The undersigned affirms that to the best of his or her knowledge, information, and belief the statements made on this form are true. Date: Representative of Issuer: (Title) (Printed name) (Signature) 11-17-2014 American LegalNet, Inc. www.FormsWorkFlow.com