Form 1-Z - Exit Report Under Regulation A (United States Securities Exchange Commission)

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OMB APPROVAL
UNITED STATES
OMB Number:
3235-0723
Expires:
June 30, 2018
SECURITIES AND EXCHANGE COMMISSION
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Washington, D.C. 20549
hours per response . . . . . . . 1.50
FORM 1-Z
EXIT REPORT UNDER REGULATION A
GENERAL INSTRUCTIONS
(1) The following information must be provided in the XML-based Form 1-Z available through the EDGAR
portal. The format shown below may differ from the electronic version available on EDGAR.
(2) An issuer filing this Form pursuant to Rule 257(a) must only complete the Preliminary Information and Part
I.
(3) An issuer filing this Form to suspend its duty to file reports under Rule 257(d) must complete the Prelimi-
nary Information and Part II. Such issuer must also provide Part I if it has not previously provided the Part I
information in a Form 1-K filing.
* * * * * *
PRELIMINARY INFORMATION
Exact name of issuer as specified in the issuer’s charter: _____________________________________
Address of Principal Executive Offi ces: __________________________________________________
__________________________________________________________________________________
Phone: (
) ____________________________
Commission File Number(s): _________________________________________________________
PART I
Summary Information Regarding the Offering and Proceeds
Date of qualification of the offering statement:______________________________
Date of commencement of the offering: ___________________________________
Amount of securities qualified to be sold in the offering:______________________
Amount of securities sold in the offering:__________________________________
Price per security: $____________________________________
The portion of aggregate sales attributable to securities sold on behalf of the issuer:
$______________________
Persons who are to respond to the collection of information contained in this form are not
required to respond unless the form displays a currently valid OMB control number.
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