Sec Form 1a Regulation A Offering Statement Page 8
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29is not applicable to the offering.
Price per security: $ ___________________________
The portion of the aggregate offering price attributable to securities being offered on behalf of the issuer:
$ __________________________
The portion of the aggregate offering price attributable to securities being offered on behalf of selling security-
holders:
$ __________________________
The portion of aggregate offering attributable to all the securities of the issuer sold pursuant to a qualifi ed offer-
ing statement within the 12 months before the qualification of this offering statement:
$ __________________________
The estimated portion of aggregate sales attributable to securities that may be sold pursuant to any other quali-
fied offering statement concurrently with securities being sold under this offering statement:
$ __________________________
Total: $ _______________________ (the sum of the aggregate offering price and aggregate sales in the four
preceding paragraphs).
Anticipated fees in connection with this offering and names of service providers:
Name of Service Provider
Fees
Underwriters:
____________________
$________________________
Sales Commissions:
____________________
$________________________
Finders’ Fees:
____________________
$________________________
Audit:
____________________
$________________________
Legal:
____________________
$________________________
Promoters:
____________________
$________________________
Blue Sky Compliance:
____________________
$________________________
CRD Number of any broker or dealer listed: _____________________________________
Estimated net proceeds to the issuer: $ __________________________________________
Clarification of responses (if necessary): ________________________________________
ITEM 5.
Jurisdictions in Which Securities are to be Offered
Using the list below, select the jurisdictions in which the issuer intends to offer the securities:
[List will include all U.S. and Canadian jurisdictions, with an option to add and remove them indi-
vidually, add all and remove all.]
Using the list below, select the jurisdictions in which the securities are to be offered by underwriters, dealers or
sales persons or check the appropriate box:
None
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