Form 1-Z - Exit Report Under Regulation A (United States Securities Exchange Commission) Page 2
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2The portion of aggregate sales attributable to securities sold on behalf of selling securityholders:
$_______________________________
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: _______________________________
Net proceeds to the issuer: $ ____________________________________________
Clarification of responses (if necessary): __________________________________
PART II
Certification of Suspension of Duty to File Reports
Title of each class of securities covered by this Form _________________________
Commission File Number(s)_____________________________________________
Approximate number of holders of record as of the certification date: ____________
Pursuant to the requirements of Regulation A, _________________________ (Name of issuer as specifi ed in
charter) certifies that it meets all of the conditions for termination of Regulation A reporting specified in Rule
257(d) and that there are no classes of securities other than those that are the subject of this Form 1-Z regarding
which the issuer has Regulation A reporting obligations. ______________________ (Name of issuer as speci-
fied in charter) has caused this certification to be signed on its behalf by the undersigned duly authorized person.
By: __________________________
Date: ______________________________
Title: _________________________
Instruction: This Part II of Form 1-Z is required by Rule 257(d) of Regulation A. An officer of the issuer or any
other duly authorized person may sign, and must do so by typed signature. The name and title of the person
signing the form must be typed or printed under the signature. The signatory to the filing must also manually
sign a signature page or other document authenticating, acknowledging or otherwise adopting his or her signa-
ture that appears in the filing. Such document must be executed before or at the time the filing is made and must
be retained by the issuer for a period of five years. Upon request, the issuer must furnish to the Commission or
its staff a copy of any or all documents retained pursuant to this instruction.
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